Focus on Adult Health Exam (elaborations)

A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Select all that apply. A. Constipation B. Tall T waves Correct C. Hyporeflexia D. Shallow respirations E. Prolonged PR interval Correct F. Hyperactive bowel sounds Correct
Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia.
Test-Taking Strategy: The knowledge that spironolactone is a potassiumsparing diuretic will assist you in determining that hyperkalemia is an adverse effect of the medication. Recalling the manifestations of hyperkalemia will direct you to the correct options. Also, note that the incorrect options are comparable or alike in that they indicate a slowed body response or function. Review the adverse effects of spironolactone and the manifestations of hyperkalemia if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Adult Pharmacology
Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and Electrolytes
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. ) St. Louis: Saunders.
Awarded 3.0 points out of 3.0 possible points.
2.ID: 8
A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a loss of appetite and complains of feeling “too full to eat.” What does the nurse encourage the client to do? Select all that apply. A. Avoid drinking fluids before and during meals Correct B. Eat a variety of dark-green vegetables, such as broccoli C. Have snacks, such as crackers and cheese, between meals D. Select foods that are easy to chew and are not gas forming Correct E. Consume high-calorie drinks, such as milkshakes, between meals
Rationale: COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and should also be avoided by the client. The nurse should also teach the client about foods that are easy to chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas-forming food, should be avoided.
Test-Taking Strategy: Use the process of elimination. Recalling that milk may increase the thickness of saliva will assist you in eliminating the option that encourages the consumption of milkshakes. Eliminate the option in which the consumption of broccoli is encouraged, because it is a gas-forming food. To select from the remaining options, note the strategic words “too full to eat” in the question and the option that encourages the client to avoid fluids before and during meals; this will direct you to the correct answers. Review dietary measures for the client with COPD if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Respiratory
Giddens Concepts: Gas Exchange, Nutrition
HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 595-596). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
3.ID: 0
A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after administration, the nurse checks the test site (see image).

The nurse documents the result of the test as: A. Positive Correct B. Negative C. Insignificant D. Indeterminate
Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive (dormant) disease.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (negative and insignificant). To select from the remaining options, note that the client has HIV, which will assist in directing you to the correct option. An area of induration is present, so the test results are not indeterminate. Review the tuberculin skin test and the procedure for interpreting the results if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Adult Health/Respiratory
Giddens Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 494, 530). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 6
A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a pressure of: A. 4 cm H2O B. 8 cm H2O C. 11 cm H2O D. 14 cm H2O Correct
Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12 cm H2O. An increased CVP reading may indicate right ventricular failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased.
Test-Taking Strategy: Focus on the client’s diagnosis. Thinking about the pathophysiology of right ventricular failure and recalling the normal CVP reading will direct you to the correct option. Review the normal CVP reading and the expected findings in right ventricular failure if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Adult Health/Cardiovascular
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. ). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 4
A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the bestway for the nurse to assess the surgical site for bleeding? A. Asking the client whether the dressing feels wet B. Looking for moisture on the top of the dressing C. Removing and replacing the dry sterile dressing every 2 hours D. Checking for moisture on the back of the dressing over the client’s neck and shoulders Correct
Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection.
Test-Taking Strategy: Note the strategic word “best.” Recalling the anatomical location of the surgical site will direct you to the correct option. Review care of the client after thyroidectomy if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Clinical Judgment, Tissue Integrity
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1399). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
6.ID: 4
A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal menu selections meet the client’s needs for wound healing and tissue repair? Select all that apply. A. Apple slices and skim milk B. Whole-milk shake and granola Correct C. Baked potato topped with cheese Correct D. Cheese and whole-wheat crackers Correct E. Cauliflower with low-fat ranc