Adult health II Final Exam Review
Questions and All Correct Answers
Graded A+ 2025.
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 displays sudden
confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli
and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by
fatigue and emotional and physical well-being.
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.
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.
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.
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.
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
,This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place
the child in a side-lying position.
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.
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 for
measuring a client's fluid volume over time
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
A nurse is caring for a client immediately following a hemodialysis treatment. 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.
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.) - Answer Assess the client's airway patency is correct. The
nurse should continually assess the client's airway during a seizure.Place a tongue depressor in
,A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the
following actions should the nurse take first? - Answer Turn the client's head to the side.
The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.
A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should
recognize that which of the following client statements indicates a need for further teaching? -
Answer "I should increase my sodium intake."
A client who has nephrotic syndrome should consume a low-sodium diet to reduce edema and
control hypertension.
A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr.
Which of the following actions is the nurse's priority? - Answer Administer pain medication.
Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological need
for comfort. Therefore, the first action the nurse should take is to administer pain medication to
relieve the client's flank pain.
A nurse is reviewing the laboratory values of a client who has chronic glomerulonephritis.
Which of the following is an expected finding for this client? - Answer BUN 100 mg/dL
The kidneys normally eliminate urea by the process of filtration and tubular secretion.
Therefore, BUN is a measure of kidney function. The client's BUN is level is above the expected
reference range and is an indication of poor kidney function.
A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin.
Which of the following information should the nurse provide? - Answer Alcohol increases the
chance of phenytoin toxicity.
The nurse should include in the home instructions that alcohol alters the blood level of
phenytoin.
, bladder distention and inability to urinate due to ineffective function of the bladder
muscles.Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused
by a lack of lack of sympathetic input.Absence of bowel sounds is correct. Spinal shock leads to
decreased peristalsis, which could cause the client to develop a paralytic ileus.Weakened gag
reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and
drooling noted with oral intake.
A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following
nursing interventions should the nurse implement? - Answer Encourage exhaling through
mouth during defecation.
The nurse should encourage the client to exhale through her mouth when defecating to
decrease strain.
A nurse is preparing medication for a client when another client has an emergency. Which of
the following actions should the nurse take? - Answer Lock the medication in a room and
finish preparing it after returning from the emergency.
No one else should have access to or administer medications the nurse has prepared. Securing
them and returning later to finishing preparing and administering them decreases the risk of
medication errors.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should
the nurse expect? - Answer Dehydration
Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.
A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved.
The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the
client has manifestations of which of the following conditions? - Answer Perforated tympanic
membrane
The client has manifestations of otitis media with a perforated tympanic membrane (eardrum).
Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation.
A nurse is assessing a client who has a traumatic head injury to determine motor function
response. Which of the following client responses to painful stimulus is expected? - Answer
Questions and All Correct Answers
Graded A+ 2025.
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 displays sudden
confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli
and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by
fatigue and emotional and physical well-being.
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.
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.
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.
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.
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
,This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place
the child in a side-lying position.
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.
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 for
measuring a client's fluid volume over time
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
A nurse is caring for a client immediately following a hemodialysis treatment. 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.
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.) - Answer Assess the client's airway patency is correct. The
nurse should continually assess the client's airway during a seizure.Place a tongue depressor in
,A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the
following actions should the nurse take first? - Answer Turn the client's head to the side.
The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to turn the client's head to the side. This action keeps the client's airway clear of
secretion to prevent aspiration.
A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should
recognize that which of the following client statements indicates a need for further teaching? -
Answer "I should increase my sodium intake."
A client who has nephrotic syndrome should consume a low-sodium diet to reduce edema and
control hypertension.
A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr.
Which of the following actions is the nurse's priority? - Answer Administer pain medication.
Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological need
for comfort. Therefore, the first action the nurse should take is to administer pain medication to
relieve the client's flank pain.
A nurse is reviewing the laboratory values of a client who has chronic glomerulonephritis.
Which of the following is an expected finding for this client? - Answer BUN 100 mg/dL
The kidneys normally eliminate urea by the process of filtration and tubular secretion.
Therefore, BUN is a measure of kidney function. The client's BUN is level is above the expected
reference range and is an indication of poor kidney function.
A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin.
Which of the following information should the nurse provide? - Answer Alcohol increases the
chance of phenytoin toxicity.
The nurse should include in the home instructions that alcohol alters the blood level of
phenytoin.
, bladder distention and inability to urinate due to ineffective function of the bladder
muscles.Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused
by a lack of lack of sympathetic input.Absence of bowel sounds is correct. Spinal shock leads to
decreased peristalsis, which could cause the client to develop a paralytic ileus.Weakened gag
reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and
drooling noted with oral intake.
A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following
nursing interventions should the nurse implement? - Answer Encourage exhaling through
mouth during defecation.
The nurse should encourage the client to exhale through her mouth when defecating to
decrease strain.
A nurse is preparing medication for a client when another client has an emergency. Which of
the following actions should the nurse take? - Answer Lock the medication in a room and
finish preparing it after returning from the emergency.
No one else should have access to or administer medications the nurse has prepared. Securing
them and returning later to finishing preparing and administering them decreases the risk of
medication errors.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should
the nurse expect? - Answer Dehydration
Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.
A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved.
The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the
client has manifestations of which of the following conditions? - Answer Perforated tympanic
membrane
The client has manifestations of otitis media with a perforated tympanic membrane (eardrum).
Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation.
A nurse is assessing a client who has a traumatic head injury to determine motor function
response. Which of the following client responses to painful stimulus is expected? - Answer
