Focus on Adult Health Exam 2024 with 100% correct answers

A nurse is caring for a client who underwent mastectomy 1 day ago. To help restore arm function on the affected side, the nurse encourages the client to use that arm to: a.) raise the arm above shoulder level b.) abduct the shoulder while drains are still in place c.)Perform finger and elbow flexion and extension exercises d.)Perform wrist and arm flexion and extension exercisesAnswer - c.)Perform finger and elbow flexion and extension exercises Rationale: Immediately after mastectomy the client is encouraged to move the fingers and hands and to flex and extend the elbow. The client may also use the arm for self-care, provided that the client does not raise the arm above shoulder level or abduct the shoulder until the postoperative drains have been removed. The health care provider will prescribe the time frame for additional exercises for the arm on the affected side. 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 c) hyporeflexia d) shallow resp e) prolonged PR interval f) hyperactive bowel soundsAnswer - b.) Tall T waves e.) Prolonged PR interval f.) Hyperactive bowel sounds 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. 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 meal b) eat a variety of dark-green vegetables such as broccoli c) have snacks, such as crackers and cheese, b/w meals d) select foods that are easy to chew and are not gas forming e) consume high-calorie drinks, such as milkshakes b/w mealsAnswer - a.) Avoid drinking fluids before and during meals d.) Select foods that are easy to chew and are not gas forming 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. A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after admini