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Adult Health Final Exam
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Adult Health Final Exam 2024-2025Skin Assessment While performing skin assessment, the nurse identifies a symmetrical
distribution of small, round, elevated lesions over the left and right upper back. What
term does the nurse use to describe the distribution of these lesions? - ANSWER
Symmetric
The nurse is going to collect a culture of a patient's suspected fungal infection of the
foot. What materials does the nurse need to gather for this examination? - ANSWER
Cotton-tipped applicators
The client is a hospitalized patient diagnosed with chronic heart failure and has
dark-skinned complexion. The nurse would most appropriately assess this client for
cyanosis by performing which of the following actions? ANWER Check the lips and oral
mucous membranes
Assessment of an older patient in the home reveals irregular bruising on the body, in
varied stages of healing, by the home health nurse. What is the FIRST action by the
nurse? - ANSWER speak with the patient privately and ask about the etiology of the
bruising
Skin Assessment The nurse observes a circular, flat, red, lesion about 5 cm around on
the middle-aged patient's ankle. To identify whether the lesion is related to intradermal
bleeding, the nurse should - ANSWER Press firmly on the lesion
Of the following integumentary assessment data for an older patient who was admitted
with bacterial pneumonia, the nurse would be most concerned about - ANSWER Reports
history of allergic rashes
ANSV When performing the health history of an older adult, the nurse discovers that the
patient has been employed in the landscaping business for 40 years. The nurse will
prepare to educate the patient about self-assessment for which clinical manifestations?
- ANSWER actinic keratosis and erythema
,A client who is about to have a biopsy of the right breast asks the nurse what the
difference is between a benign and malignant tumor. Which is the correct response by
the nurse? ANSWER "Malignant tumors may spread to other tissues or organs"
A nurse is providing care for a patient who smokes 2 packs/day. To decrease the
patient's risk of lung cancer the most, which nursing action would be most helpful? -
ANSWER Discuss the risks associated with cigarettes during each visit with the patient
The nurse should include which food option when teaching diet to a patient who will be
receiving external beam radiation to the abdomen for cancer? - ANSWER Roasted
chicken
A patient is found to have cervical cancer that is staged as Tis, N0, M0. The patient asks
the nurse to explain what the letters and numbers mean. Which response by the nurse is
most appropriate? ANSWER "the cancer involves only the cervix"
During a teaching session for a patient with a new diagnosis of acute leukemia, the
patient appears restless and is looking away, never making eye contact. After teaching
the complications related to chemotherapy, the patient requests the nurse to repeat all
of the information. Based on this assessment, which nursing diagnosis is most
appropriate for the patient? - ANSWER Risk for ineffective health maintenance related
to anxiety about new leukemia
A hospitalized patient who has received chemotherapy for leukemia develops
neutropenia. Which observation by the nurse would indicate a need for further teaching
- ANSWER The patients visitors bring in some fresh peaches from home
The nurse receives change-of-shift report on the oncology unit. Which patient should the
nurse assess first? - ANSWER 24-year-old patient who received neck radiation and has
blood oozing from the neck
The patient is an older adult with colorectal cancer, receiving IV fluids at 175mL/hour
along with his prescribed chemotherapy. Which of the following findings would be most
significant for the nurse to communicate to the health care provider? ANSWER Patient
, has audible crackles in the midline posterior chest
A patient has an open leg wound and has a WBC count of 13,500/uL with a band count of
11%. What does the nurse do first? - ANWER Obtain wound cultures
A patient has an open surgical wound to the abdomen that contains deep pink
granulation tissue. How does the nurse document this wound? - ANWER Red wound
The patient is admitted to the hospital from a long-term care facility with a sacral
pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. The
nurse would classify this pressure ulcer as which of the following? ANSWER Stage III
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is
being cared for at home by his mother. To prevent further tissue damage, which of the
following instructions are most important for the nurse to teach the mother? ANSWER
Turn the patient at least every 2 hours
A new nurse changes the dressing of a client with a stage II left heel pressure ulcer.
Which action by the new nurse indicates a need for further teaching regarding care of a
pressure ulcer? ANSWER The new nurse cleanses the ulcer with a sterile dressing
soaked in half-strength peroxide
Which of the following is the most important discovery for the nurse to communicate to
the health care provider during treatment of a patient receiving negative pressure
wound therapy? - ANSWER Low serum albumin level
The nurse is providing care for a client with diabetes who underwent abdominal surgery
3 days ago. Which of the following findings is the most important for the nurse to notify
the health care provider about? - ANSR Separation of the proximal wound edges by 1 cm
The nurse has just received a change-of-shift report. Which of the following clients
should the nurse visit first? - ANSR The client who has been receiving chemotherapy
and whose temperature is 102 F
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