Focus on Adult Health Exam
questions n answers already passed
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. -
correct answer ✔✔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.
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. - correct answer
✔✔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.
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. - correct answer ✔✔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).
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. - correct answer ✔✔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
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. - correct answer ✔✔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?
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. - correct answer ✔✔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.
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 - correct answer ✔✔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?
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. - correct answer ✔✔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?
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). - correct answer ✔✔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.
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. - correct answer ✔✔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?
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 - correct answer ✔✔The nurse is teaching a client with newly diagnosed
diabetes mellitus who has been prescribed NPH insulin how to recognize the signs of
questions n answers already passed
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. -
correct answer ✔✔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.
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. - correct answer
✔✔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.
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. - correct answer ✔✔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).
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. - correct answer ✔✔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
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. - correct answer ✔✔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?
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. - correct answer ✔✔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.
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 - correct answer ✔✔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?
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. - correct answer ✔✔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?
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). - correct answer ✔✔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.
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. - correct answer ✔✔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?
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 - correct answer ✔✔The nurse is teaching a client with newly diagnosed
diabetes mellitus who has been prescribed NPH insulin how to recognize the signs of
