FOCUS ON ADULT HEALTH - Questions, Answers and Rationales

Focus on Adult Health. ID: 4
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., & ...continued...