Focus on Adult Health Exam
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. - ANS 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. - ANS 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). - ANS 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 - ANS 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? - ANS 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. - ANS
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? - ANS 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? - ANS 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. - ANS 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? - ANS 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. - ANS 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 intake is
insufficient. The nurse teaches the client to be alert for signs and symptoms of hypoglycemia, including
anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse,
shakiness, and hunger. The other options are signs and symptoms of hyperglycemia
Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the
client about this type of insulin? Select all that apply - ANS It does not have a peak effect.
It is usually given once daily, at bedtime.
It usually has a 24-hour duration of action
Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with
no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably
at bedtime. Glargine insulin may not be mixed in a syringe with other insulin.
A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse
immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then
tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test
reads: - ANS 7.40
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. - ANS 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. - ANS 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). - ANS 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 - ANS 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? - ANS 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. - ANS
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? - ANS 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? - ANS 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. - ANS 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? - ANS 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. - ANS 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 intake is
insufficient. The nurse teaches the client to be alert for signs and symptoms of hypoglycemia, including
anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse,
shakiness, and hunger. The other options are signs and symptoms of hyperglycemia
Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the
client about this type of insulin? Select all that apply - ANS It does not have a peak effect.
It is usually given once daily, at bedtime.
It usually has a 24-hour duration of action
Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with
no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably
at bedtime. Glargine insulin may not be mixed in a syringe with other insulin.
A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse
immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then
tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test
reads: - ANS 7.40
