(Adult Health)
1.A male client diagnosed with primary hyperaldosteronism is receiving
spironolactone. Which potential side effect should the nurse educate the
client regarding?
Select all that apply
1. Erectile dysfunction
2. Gastrointestinal upset
3. Gynecomastia
4. Hypernatremia
5. Hypokalemia
ANS 1. Erectile dysfunction
2.Gastrointestinal upset
3. Gynecomastia
2. The nurse is preparing discharge teaching for a client diagnosed with
peripheral vascular disease (PVD). Which teaching points should the nurse
include about foot and leg care?
Select all that apply
1. Wear soft cotton socks
2. Avoid hot whirlpools
3. Rub feet dry
,4. Wash feet every other day
5. Clear pathways in house
ANS 1. Wear soft cotton socks
2. Avoid hot whirlpools
5. Clear pathways in house
3. The nurse is caring for a client diagnosed with Guillain-Barre' Syndrome.
What assessment finding would the nurse expect see in this client?
Select all that apply
1. Areflexia
2. Dysphagia
3. Hemiplegia
4. Orthostatic hypotension
5. Hypertonia
ANS 1. Areflexia
2. Dysphagia
4. Orthostatic hypotension
4. A client received a severe burn to the right hand. When dressing the
wound, it is important for the nurse to do what?
1. Apply a wet to dry dressing for debridement.
2. Wrap each digit individually to prevent webbing.
3. Open blisters to allow drainage prior to dressing.
4. Allow the client to do as much of the dressing change as possible.
,ANS 2. Wrap each digit individually to prevent webbing.
5.The edrophonium (Tensilon) test has been prescribed for a client. Which
statement by the client would indicate to the nurse that the client
understands this test?
1. "This medication will be given to me as an IM injection immediately after
my muscles are tired."
2. "This test will determine if I have multiple sclerosis."
3. "The test is positive if my muscles do not get stronger after injection
with this medication."
4. "I will be asked to perform a repetitive movement to test my muscles."
ANS 4. "I will be asked to perform a repetitive movement to test my
muscles."
6.A client is admitted to the emergency department after sustaining burns
to the chest and legs during a house fire. Which assessment should the
nurse perform immediately?
1. Respiratory
2. Cardiac
3. Airway
4. Neurological
ANS 3. Airway
7.What is the priority nursing action for a client that was admitted with
, tingling of the toes and feet after having the flu for several days when the
client begins to have numbness in the legs and hips?
1. Notify the primary healthcare provider
2. Monitor for paresthesia in the fingers and hands
3. Insert an indwelling urinary catheter
4. Assist the client with performing passive range of motion
ANS 1. Notify the primary healthcare provider
8.A client reports excruciating paroxysmal facial pain occurring after feeling
a cool breeze and drinking cold beverages. Based on this client's reports,
what disorder does the nurse suspect?
1. Bell's palsy
2. Submucous cleft palate
3. Trigeminal neuralgia
4. Temporomandibular joint disorder (TMD)
ANS 3. Trigeminal neuralgia
9.The nurse is reviewing sequential lab results on a newly admitted client
with multiple health issues. Critical changes in which body system require
the nurse to immediately notify the primary healthcare provider?
1. Renal
2. Endocrine
3. Pulmonary