Adult Health Studies

Adult Health 2 Final 2025/2026. New!!!
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14. The triage nurse receives a call from a community member who is driving an
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unconscious friend with multiple injuries after a motorcycle accident to the hospital. The
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caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the
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nurse will obtain
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a. a liter of lactated Ringer's solution.
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b. 500 ml of 5% albumin.
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c. two 14-gauge IV catheters.
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d. a retention cathete - Answer Correct Answer: C
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Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat
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hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to
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administer normal saline. Lactated Ringer's solution should be used cautiously and will not
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be ordered until the patient had been assessed for possible liver abnormalities. Although
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colloids may sometimes be used for volume expansion, it is generally accepted that
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crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would
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likely be ordered, but in the 1 minute that the nurse has to obtain supplies, the IV catheters
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would take prio
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6. A patient with Bell's palsy refuses to eat while others are present because of
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embarrassment about drooling. The best response by the nurse to the patient's behavior is
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to
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a. respect the patient's desire and arrange for privacy at mealtimes.
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b. offer the patient liquid nutritional supplements at frequent intervals.
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c. discuss the patient's concerns with visitors who arrive at mealtimes.
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d. teach the patient to chew food on the unaffected side of the mouth. - Answer Correct
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Answer: A
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Rationale: The patient's desire for privacy should be respected to encourage adequate ty ty ty ty ty ty ty ty ty ty ty




nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's
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enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the
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patient's embarrassment with visitors unless the patient wishes to share this information.
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Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food
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but will not decrease the drooling.
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A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of
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210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be
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done first?
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a.) Place the client flat in bed
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b.) Assess patency of the indwelling urinary catheter
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c.) Give one SL nitroglycerin tablet
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,d.) Raise the head of the bed immediately to 90 degrees - Answer d.) Raise the head of the
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bed immediately to 90 degrees
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Rationale:
Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia
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are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a
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full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood
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pressure to increase even more. The indwelling urinary catheter should be assessed
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immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce
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preload; it isn't used for hypertension or dysreflexia.
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A 22-year-old patient is brought to the ICU following a motorcycle accident resulting in a C5
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fracture. Cervical traction has been established. During the initial phase of care, the nurse
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is most concerned about his respiratory function because
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A. At the C5 level there is total loss of diaphragmatic and intercostal muscle function
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B. Extension of edema at the site of injury may affect phrenic nerve function
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C. Without abdominal muscle control, he cannot adequately cough to clear his lungs
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D. Immobilization of the patient spine with cervical traction promotes pooling of respiratory
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secretions - Answer B. Extension of edema at the site of injury may affect phrenic nerve
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function
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A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this
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phase of the patient's illness, the most essential assessment for the nurse to carry out is
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a. monitoring the cardiac rhythm continuously.
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b. determining the level of consciousness q2hr.
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c. evaluating sensation and strength of the extremities.
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d. performing constant evaluation of respiratory function. - Answer Correct Answer: D
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Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, ty ty ty ty ty ty ty ty ty ty




and the nurse should monitor respiratory function continuously. The other assessments
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will also be included in nursing care, but they are not as important as respiratory
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assessment.
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A 28-year-old patient has newly diagnosed multiple sclerosis and asks many questions
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about the disease. In the nurse's explanation of the process of multiple sclerosis, which
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information is most accurate?
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A. Multiple sclerosis is an untreatable viral disease that destroys the basal ganglia in the
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brain.
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B. Nerve impulses travel too fast over nerves that have lost their myelin coat, overloading
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the brain
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C. An autoimmune process causes gradual destruction of the myelin sheath of nerves in
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the brain and spinal cord
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D. In multiple sclerosis, antibodies are produced against acetycholine receptors, resulting
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in blocked muscle contraction - Answer C. An autoimmune process causes gradual
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destruction of the myelin sheath of nerves in the brain and spinal cord
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,A 28-year-old patient has returned home following extensive rehabilitation for a C8 spinal
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cord injury. The home care nurse visits and notices that the patient's mother and husband
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are performing many of the activities of daily living that the patient was managing during
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rehabilitation. Which action by the nurse is most appropriate at this time?
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A. Recognize that it is important for the family to be involved in her care and support their
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activities
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B. Unclude the mother and husband in developing a plan of care to increase the patient's
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independence
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C. Tell the mother and husband to stop performing care that the patient can do herself
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D. Suggest to the patient that she do her own care as she has been taught - Answer B.
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Unclude the mother and hysband in developing a plan of care to increase the patient's
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independence
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A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To
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evaluate the patient's expected response to this medication, what is most important for the
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nurse to assess?
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a Improved skin turgor
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b Decreased cardiac rate
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c Improved finger perfusion
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d Decreased mean arterial pressure - Answer c Improved finger perfusion
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Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, ty ty ty ty ty ty ty ty ty ty




most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel
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blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into
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the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the
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fingertips is improved and vasospastic attacks reduced. Diltiazem may decrease heart
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rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor
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is most often a reflection of hydration status.
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A 32-yo physical therapist is admitted to the hospital with possible deep vein
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thrombophlebitis. Her left calf is swollen and tender to touch. Physician orders include
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duplex ultrasound scanning left leg, bed rest with feed elevated, and BRP for BM's only.
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Duplex ultrasound scanning confirms the presence of a deep vein thrombosis, and the
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physician orders continuous IV heparin infusion. Which intervention does the nurse plan
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while the patient is receiving the heparin infusion?
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a. Have vitamin K available in case the patient bleeds from the action of heparin.
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b. Teach the patient to given herself subcutaneous heparin injections for long-term home
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therapy.
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c. Maintain strict bed rest to prevent accidental trauma.
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d. Notify the physician if the PTT value is greater than 180 seconds. - Answer d. Notify the
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physician if the PTT value is greater than 180 seconds.
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, A 32-yo physical therapist is admitted to the hospital with possible deep vein
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thrombophlebitis. Her left calf is swollen and tender to touch. Physician orders include
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duplex ultrasound scanning left leg, bed rest with feed elevated, and BRP for BM's only.
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Which method should the nurse use to elevate the patient's feet?
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a. Elevate the foot of the bed above the level of her heart.
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b. Place two pillows under the calf of her affected leg.
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c. Gatch the bed at the knee and place pillows under her feet.
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d. Place one pillow under her thighs and two pillows under her lower legs. - Answer a.
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Elevate the foot of the bed above the level of her heart.
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A 38-year-old woman has newly diagnosed multiple sclerosis (MS) and asks the nurse
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what is going to happen to her. What is the best response by the nurse?
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a. "You will have either periods of attacks and remissions or progression of nerve damage
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over time."
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b. "You need to plan for a continuous loss of movement, sensory functions, and mental
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capabilities."
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c. "You will most likely have a steady course of chronic progressive nerve damage that will
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change your
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personality."
d. "It is common for people with MS to have an acute attack of weakness and then not to
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have any other symptoms
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for years." - Answer a. "You will have either periods of attacks and remissions or
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progression of nerve damage over time."
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Most patients with multiple sclerosis (MS) have
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remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial ty ty ty ty ty ty ty ty ty




course followed by progression with or without occasional relapses, minor remissions, and
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plateaus that progressively cause loss of motor, sensory, and cerebellar functions.
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Intellectual function generally remains intact but patients may experience anger,
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depression, or euphoria. A few people have chronic progressive deterioration and some
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may experience only occasional and mild symptoms for several years after onset.
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A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with
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a venous thromboembolism (VTE) and prescribed unfractionated heparin. What
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laboratory test should the nurse review to evaluate the expected effect of the heparin?
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A. Platelet count
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B. Activated clotting time (ACT)
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C. International normalized ratio (INR)
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D. Activated partial thromboplastin time (APTT) - Answer D. APTT
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A 40-year-old man tells the nurse he has a diagnosis for the color and temperature
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changes of his limbs but can't remember the name of it. He says he must stop smoking and
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avoid trauma and exposure of his limbs to cold temperatures to get better. This description
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should allow the nurse to ask the patient if he has which diagnosis?
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