Adult Health II Final Exam Questions and Answers
100% Verified Graded A+
1. A nurse on a medical unit is caring for a client who suddenly becomes confused and
drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm
Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse
perform?
Answer> Complete a neurological check. Neurological assessment is an appropriate
nursing intervention when a client dis- plays sudden confusion. Sensory alterations can
occur when a client is experiencing multiple sensory stimuli and can result in inappropriate
sensory responses. Toler- ance to stimuli may be affected by fatigue and emotional and
physical well-being.
2. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle
glaucoma and a new prescription for timolol eye drops. Which of the following
instructions should the nurse provide?
Answer> The medication should be applied on a regular schedule for the rest of the client's
life.
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136
,Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow,
or decrease its production, or both. The client must continue the eye drops on an
uninterrupted basis for life to maintain intraocular pressure at an acceptable level.
3. A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain
that which of the following conditions can increase the risk for renal calculi?
Answer> Dehydration
Dehydration can cause hypercalcemia which increases the risk for renal stone
formation. Inadequate fluid intake can result in urinary stasis and promote the
formation of calculi.
4. A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed
selegiline, an MAOI. Which of the following foods should the nurse eliminate?
Answer> Cheddar cheese
The nurse should eliminate aged cheeses from the diet of a client who is prescribed
selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.
5. A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the
following findings should the nurse expect?
Answer> Hyporeflexia
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136
,The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and
hyperreflexia.
6. A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which
of the following actions is the nurse's priority?
Answer> Position the child side-lying.
This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should
place the child in a side-lying position.
7. A nurse is discussing kidney transplant with a client who has end-stage renal disease
(ESRD). Which of the following should the nurse identify as a contraindication for this
treatment?
Answer> Alcohol use disorder
The nurse should identify that a substance use disorder is a contraindication for kidney
transplant.
8. A nurse is assessing a client who has chronic kidney disease for fluid volume increase.
Which of the following provides a reliable measure of fluid retention?
Answer> Daily weight
Obtaining a client's daily weight and comparing it to previous weights is a reliable method
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136
, for measuring a client's fluid volume over time
9. A nurse is caring for a client who is experiencing Cushing's Triad following a subdural
hematoma. Which of the following medications should the nurse plan to administer?
Answer> Mannitol 25%
Cushing's Triad is an indication that the client is experiencing increased intracranial
pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes
diuresis to treat cerebral edema
10. A nurse is caring for a client immediately following a hemodialysis treat- ment. For
which of the following manifestations will the nurse administer a PRN dose of
phenytoin?
Answer> Headache, restlessness
Headache and restlessness are manifestations of disequilibrium syndrome, which occurs
during or after hemodialysis due to the rapid shift of fluids, pH, and osmolarity between fluid
and blood that occurs.. This condition can cause cerebral edema leading to seizures and
coma, and a PRN dose of the anticonvulsant phenytoin should be administered.
11. A nurse is caring for a child who is having a seizure.Which of the following actions
should the nurse take? (Select all that apply.)
4/
136
100% Verified Graded A+
1. A nurse on a medical unit is caring for a client who suddenly becomes confused and
drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm
Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse
perform?
Answer> Complete a neurological check. Neurological assessment is an appropriate
nursing intervention when a client dis- plays sudden confusion. Sensory alterations can
occur when a client is experiencing multiple sensory stimuli and can result in inappropriate
sensory responses. Toler- ance to stimuli may be affected by fatigue and emotional and
physical well-being.
2. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle
glaucoma and a new prescription for timolol eye drops. Which of the following
instructions should the nurse provide?
Answer> The medication should be applied on a regular schedule for the rest of the client's
life.
1/
136
,Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow,
or decrease its production, or both. The client must continue the eye drops on an
uninterrupted basis for life to maintain intraocular pressure at an acceptable level.
3. A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain
that which of the following conditions can increase the risk for renal calculi?
Answer> Dehydration
Dehydration can cause hypercalcemia which increases the risk for renal stone
formation. Inadequate fluid intake can result in urinary stasis and promote the
formation of calculi.
4. A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed
selegiline, an MAOI. Which of the following foods should the nurse eliminate?
Answer> Cheddar cheese
The nurse should eliminate aged cheeses from the diet of a client who is prescribed
selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.
5. A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the
following findings should the nurse expect?
Answer> Hyporeflexia
2/
136
,The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and
hyperreflexia.
6. A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which
of the following actions is the nurse's priority?
Answer> Position the child side-lying.
This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should
place the child in a side-lying position.
7. A nurse is discussing kidney transplant with a client who has end-stage renal disease
(ESRD). Which of the following should the nurse identify as a contraindication for this
treatment?
Answer> Alcohol use disorder
The nurse should identify that a substance use disorder is a contraindication for kidney
transplant.
8. A nurse is assessing a client who has chronic kidney disease for fluid volume increase.
Which of the following provides a reliable measure of fluid retention?
Answer> Daily weight
Obtaining a client's daily weight and comparing it to previous weights is a reliable method
3/
136
, for measuring a client's fluid volume over time
9. A nurse is caring for a client who is experiencing Cushing's Triad following a subdural
hematoma. Which of the following medications should the nurse plan to administer?
Answer> Mannitol 25%
Cushing's Triad is an indication that the client is experiencing increased intracranial
pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes
diuresis to treat cerebral edema
10. A nurse is caring for a client immediately following a hemodialysis treat- ment. For
which of the following manifestations will the nurse administer a PRN dose of
phenytoin?
Answer> Headache, restlessness
Headache and restlessness are manifestations of disequilibrium syndrome, which occurs
during or after hemodialysis due to the rapid shift of fluids, pH, and osmolarity between fluid
and blood that occurs.. This condition can cause cerebral edema leading to seizures and
coma, and a PRN dose of the anticonvulsant phenytoin should be administered.
11. A nurse is caring for a child who is having a seizure.Which of the following actions
should the nurse take? (Select all that apply.)
4/
136
