Focus on Adult Health Exam Questions with
100% Verified Correct Answers
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. - Correct Answer Tall T waves
Prolonged PR interval
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. - Correct Answer Avoid drinking fluids
before and during meals
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 administration, the nurse checks the test site (see image). - Correct Answer Positive
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.
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 - Correct Answer 14 cm H2O
,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.
A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way
for the nurse to assess the surgical site for bleeding? - Correct Answer Checking for moisture on the
back of the dressing over the client's neck and shoulders
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.
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. - Correct Answer Whole-milk shake and granola
Baked potato topped with cheese
Cheese and whole-wheat crackers
Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major
burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the
client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat
products are acceptable choices. Though fresh fruits and vegetables and skim milk are high in
nutrients, higher-calorie foods, including versions of dairy products prepared with whole milk, are
preferable in this situation.
A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching
the client about measures to manage the disorder, tell the client to take on a daily basis? - Correct
Answer Calcium carbonate with vitamin D
Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased.
The client with hypoparathyroidism is likely to have low calcium and high phosphate levels and
should consume a diet high in calcium but low in phosphorus. Additionally, the generally used
treatment is calcium supplementation (either as calcium carbonate or calcium citrate) coupled with
vitamin D supplementation. Vitamin C supplementation is not a treatment measure for this disorder.
Beta-carotene is incorrect, because a client with hypoparathyroidism typically has an increased
phosphorus level
, A nurse participating in a free health screening at the local mall obtains a random blood glucose level
of 190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise
healthy client. What should the nurse tell the client to do next? - Correct Answer Call his health care
provider to have these values rechecked as soon as possible
Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia,
polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma
glucose level greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma glucose level greater than
140 mg/dL (7.8 mmol/L) on two separate occasions are all diagnostic of diabetes mellitus. The total
cholesterol should be less than 200 mg/dL (5.2 mmol/L). Confirmation of this client's results is
needed to ensure appropriate diagnosis and therapy.
Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides
information to the client about the medication. Which occurrences does the nurse tell the client to
report to the health care provider? Select all that apply. - Correct Answer Chest pain
Palpitations
Rapid heart rate
Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism if the
dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high.
Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which
may result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain,
palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms
of hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium).
A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower
extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the
highest priority for this client? - Correct Answer Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in
the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system
impairment. Therefore the highest priority nursing problem is increased risk for injury. Increased risk
of depression and change in body image are more psychosocial in nature and, as such, are secondary
needs. A lower level of physical activity may be a problem but is not the priority.
The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed NPH
insulin how to recognize the signs of hypoglycemia. The client states that he must look for certain
signs and symptoms in the late afternoon, indicating to the nurse that he has understood the
instructions. What are these signs and symptoms? Select all that apply. - Correct Answer Shakiness
Blurred vision
Feelings of hunger
Rationale: The client taking NPH insulin experiences peak medication effects 6 to 12 hours after
administration. When the medication's action peaks, the client is at risk of hypoglycemia if food
100% Verified Correct Answers
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. - Correct Answer Tall T waves
Prolonged PR interval
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. - Correct Answer Avoid drinking fluids
before and during meals
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 administration, the nurse checks the test site (see image). - Correct Answer Positive
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.
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 - Correct Answer 14 cm H2O
,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.
A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way
for the nurse to assess the surgical site for bleeding? - Correct Answer Checking for moisture on the
back of the dressing over the client's neck and shoulders
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.
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. - Correct Answer Whole-milk shake and granola
Baked potato topped with cheese
Cheese and whole-wheat crackers
Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major
burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the
client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat
products are acceptable choices. Though fresh fruits and vegetables and skim milk are high in
nutrients, higher-calorie foods, including versions of dairy products prepared with whole milk, are
preferable in this situation.
A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching
the client about measures to manage the disorder, tell the client to take on a daily basis? - Correct
Answer Calcium carbonate with vitamin D
Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased.
The client with hypoparathyroidism is likely to have low calcium and high phosphate levels and
should consume a diet high in calcium but low in phosphorus. Additionally, the generally used
treatment is calcium supplementation (either as calcium carbonate or calcium citrate) coupled with
vitamin D supplementation. Vitamin C supplementation is not a treatment measure for this disorder.
Beta-carotene is incorrect, because a client with hypoparathyroidism typically has an increased
phosphorus level
, A nurse participating in a free health screening at the local mall obtains a random blood glucose level
of 190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise
healthy client. What should the nurse tell the client to do next? - Correct Answer Call his health care
provider to have these values rechecked as soon as possible
Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia,
polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma
glucose level greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma glucose level greater than
140 mg/dL (7.8 mmol/L) on two separate occasions are all diagnostic of diabetes mellitus. The total
cholesterol should be less than 200 mg/dL (5.2 mmol/L). Confirmation of this client's results is
needed to ensure appropriate diagnosis and therapy.
Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides
information to the client about the medication. Which occurrences does the nurse tell the client to
report to the health care provider? Select all that apply. - Correct Answer Chest pain
Palpitations
Rapid heart rate
Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism if the
dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high.
Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which
may result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain,
palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms
of hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium).
A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower
extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the
highest priority for this client? - Correct Answer Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in
the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system
impairment. Therefore the highest priority nursing problem is increased risk for injury. Increased risk
of depression and change in body image are more psychosocial in nature and, as such, are secondary
needs. A lower level of physical activity may be a problem but is not the priority.
The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed NPH
insulin how to recognize the signs of hypoglycemia. The client states that he must look for certain
signs and symptoms in the late afternoon, indicating to the nurse that he has understood the
instructions. What are these signs and symptoms? Select all that apply. - Correct Answer Shakiness
Blurred vision
Feelings of hunger
Rationale: The client taking NPH insulin experiences peak medication effects 6 to 12 hours after
administration. When the medication's action peaks, the client is at risk of hypoglycemia if food
