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Focus on Adult Health Exam/100 Answered Questions
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Focus on Adult Health Exam/100Answered Questions
A nurse is caring for a client who underwent mastectomy 1 day ago. To help
restore arm function on the affected side, the nurse encourages the client to
use that arm to:
a.) raise the arm above shoulder level
b.) abduct the shoulder while drains are still in place
c.)Perform finger and elbow flexion and extension exercises
d.)Perform wrist and arm flexion and extension exercises - -c.)Perform finger
and elbow flexion and extension exercises
Rationale: Immediately after mastectomy the client is encouraged to move
the fingers and hands and to flex and extend the elbow. The client may also
use the arm for self-care, provided that the client does not raise the arm
above shoulder level or abduct the shoulder until the postoperative drains
have been removed. The health care provider will prescribe the time frame
for additional exercises for the arm on the affected side.
-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.
a) constipation
b) tall T waves
c) hyporeflexia
d) shallow resp
e) prolonged PR interval
f) hyperactive bowel sounds - -b.) Tall T waves
e.) Prolonged PR interval
f.) 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
a) avoid drinking fluids before and during meal
b) eat a variety of dark-green vegetables such as broccoli
,c) have snacks, such as crackers and cheese, b/w meals
d) select foods that are easy to chew and are not gas forming
e) consume high-calorie drinks, such as milkshakes b/w meals - -a.) Avoid
drinking fluids before and during meals
d.) 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). - -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
a.) 8 cm CVP
b.) 4 cm H2O
c.) 14 cm H2O
d.) 11 cm CVP - -c.) 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 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.
a) apple slices and skim milk
b) whole milk a shake and granola
,c) baked potato topped with cheese
d) cheese and whole wheat crackers
e) cauliflower with low fat ranch dip - -b.) Whole-milk shake and granola
c.)Baked potato topped with cheese
d.) 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 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?
a.) Checking for moisture on the back of the dressing over the client's neck
and shoulders
b.)Asking the client whether the dressing feels wet
c.)Replacing the dressing frequently
d.)Replace the dry sterile dressing every 2 hours - -a.) 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 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?
a.) Calcium carbonate with supplementation
b.)Calcium carbonate with Beta-carotene
c.) Calcium carbonate with vitamin D
d.)Calcium carbonate with vitamin K - -c.) 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?
a.) Continue to monitor the pt
b.) call supervisor
c.) Call his health care provider to have these values rechecked as soon as
possible
d.) call charge nurse - -c.) 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.
a) lethargy
b) chest pain
c) palpitations
d) weight gain
e) constipation
f) rapid heart rate - -b.)Chest pain
c.)Palpitations
f.)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).
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