NURSING MISC Focus on Adult Health Exam(Questions with Answers)100% Correct, LATEST; Fall 2019

The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed NPH insulin how to recognize the signs of hypoglycemia. The client states that he must look for certain signs and symptoms in the late afternoon, indicating to the nurse that he has understood the instructions. What are these signs and symptoms? Select all that apply. A. Shakiness Correct B. Drowsiness C. Blurred vision Correct D. Increased thirst E. Feelings of hunger Correct F. Nausea and vomiting
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.
Test-Taking Strategy: Note the subject, the signs and symptoms of hypoglycemia. Recalling the pathophysiology of hypoglycemia will direct you to the correct answers. Review the signs and symptoms of hypoglycemia and hyperglycemia if this question was difficult.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Endocrine
Giddens Concepts: Client Education, Glucose Regulation
HESI Concepts: Teaching and Learning/Patient Education, Glucose Regulation
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1175). St. Louis: Mosby.
Awarded 3.0 points out of 3.0 possible points.
12.ID: 5
Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the client about this type of insulin? Select all that apply. A. It does not have a peak effect. Correct B. It is usually given once daily, at bedtime. Correct C. It usually has a 24-hour duration of action. Correct D. It may be mixed in a syringe with regular insulin. E. Its onset of action comes 4 hours after administration.
Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin.
Test-Taking Strategy: Knowledge regarding glargine insulin is required to answer this question. Review of the characteristics of glargine insulin if this question was difficult for you.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Client Education, Glucose Regulation
HESI Concepts: Teaching and Learning/Patient Education, Glucose Regulation
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 624 ) St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care.(7th ed., p. 1431). St. Louis: Saunders.
~ Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin.
Test-Taking Strategy: Knowledge regarding glargine insulin is required to answer this question. Review of the characteristics of glargine insulin if this question was difficult for you.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Client Education, Glucose Regulation
HESI Concepts: Teaching and Learning/Patient Education, Glucose Regulation
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 624 ) St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care.(7th ed., p. 1431). St. Louis: Saunders.
Awarded 3.0 points out of 3.0 possible points.
13.ID: 3
A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads: A. 7.28 B. 7.30 C. 7.40 Correct D. 7.50
Rationale: First aid after a chemical burn to the eye consists of irrigation of the eye with copious amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete, the victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before, during, and after irrigations to determine the pH and to ascertain whether the substance was acid or alkaline. The normal body pH is 7.40.
Test-Taking Strategy: Knowledge that the normal body pH is 7.40 will direct you to the correct option. pH values of 7.28 and 7.30 indicate acidic condition, whereas 7.50 indicates an alkaline condition. Review care of the client who has sustained a chemical splash to the eye if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Giddens Concepts: Clinical Judgment, Tissue Integrity
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity
Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 288). St. Louis: Elsevier.
American Family Physician , Ocular Emergencies.
Awarded 1.0 points out of 1.0 possible points.
14.ID: 0
A nurse educator conducts an informational session for emergency department nurses about smallpox. Which statements by the nurse educator are correct? Select all that apply. A. Smallpox is transmitted by way of the enteric route. B. Ealy clinical manifestations include influenza-like symptoms. Correct C. Vacinating within 3 days of exposure lowers the risk of active disease. Correct D. Th infected person is infectious from the onset of the rash until the scabs separate. Correct E. A difuse red rash noted over the entire body is the first manifestation of the infection. F. Airbrne precautions are not necessary if the nurse has received the smallpox vaccine.
Rationale: Clinical manifestations of smallpox include sudden onset of influenza-like symptoms, including fever, malaise, headache, prostration, severe back pain, and, less often, abdominal pain and vomiting. Two to 3 days later, the temperature falls and the client feels somewhat better, at which time the characteristic rash appears, first on the face, hands, and forearms and then, after a few days, on the trunk. Lesions also develop in the mucous membranes of the nose and mouth and ulcerate very soon after their formation, releasing large amounts of virus into the mouth and throat. Smallpox is transmitted from person to person in infected aerosols and air droplets, especially if the symptoms include coughing. A person is considered infectious at the onset of the rash and until the rash scabs over, which is approximately 3 weeks. Airborne precautions are required even if the nurse has been vaccinated against smallpox, because the vaccine does not give reliable lifelong immunity. Those vaccinated within 2 or 3 days of exposure have a lesser risk of active disease.
Test-Taking Strategy: Specific knowledge regarding the characteristics of smallpox is required to answer the question. Recalling its manifestations, the appearance of the rash, and the mode of transmission will help you answer correctly. Review the characteristics of smallpox infection if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Biological/Chemical Warfare
Giddens Concepts: Client Education, Infection
HESI Concepts: Infection, Teaching and Learning/Patient Education
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 448). St. Louis: Saunders.
Awarded 3.0 points out of 3.0 possible points.
15.ID: 5
A nurse educator conducts an informational session for hospital nurses about skin anthrax. Which statements by the nurse educator are correct? Select all that apply. A. Skin anthrax can lead to septicemia if it goes untreated. Correct B. Symptoms may appear as soon as 24 hours after exposure. Correct C. This type of anthrax results from the inhalation of spores. D. Contact precautions are not always necessary with skin anthrax. Correct E. Early clinical manifestations include mild upper respiratory symptoms.
Rationale: Skin anthrax is transmitted through direct contact when spores from contaminated products enter the skin through cuts or abrasions. Person-toperson spread does not occur; therefore, contact precautions may not always be necessary. Symptoms may appear as early as 24 hours or as long as up to 7 days after exposure. Antibiotic treatment cures the skin infection, but, left untreated, skin anthrax results in overwhelming septicemia and death. Inhalation anthrax, transmitted through the inhalation of spores, begins with mild, nonspecific upper respiratory and flulike symptoms, including fever, muscle aches, and fatigue.
Test-Taking Strategy: Use the process of elimination and focus on the subject, skin anthrax. Eliminate the options that are comparable or alike in that they apply to inhalation anthrax. Review the characteristics of skin anthrax if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Biological/Chemical Warfare
Giddens Concepts: Infection, Safety
HESI Concepts: Infection, Safety
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 448). St. Louis: Saunders.
~ Rationale: Skin anthrax is transmitted through direct contact when spores from contaminated products enter the skin through cuts or abrasions. Personto-person spread does not occur; therefore, contact precautions may not always be necessary. Symptoms may appear as early as 24 hours or as long as up to 7 days after exposure. Antibiotic treatment cures the skin infection, but, left untreated, skin anthrax results in overwhelming septicemia and death. Inhalation anthrax, transmitted through the inhalation of spores, begins with mild, nonspecific upper respiratory and flulike symptoms, including fever, muscle aches, and fatigue.
Test-Taking Strategy: Use the process of elimination and focus on the subject, skin anthrax. Eliminate the options that are comparable or alike in that they apply to inhalation anthrax. Review the characteristics of skin anthrax if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Biological/Chemical Warfare
Giddens Concepts: Infection, Safety
HESI Concepts: Infection, Safety
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 448). St. Louis: Saunders.
Awarded 3.0 points out of 3.0 possible points.
16.ID: 8
A nurse is conducting an admission assessment of a client hospitalized with a diagnosis of Meniere’s disease. Which question would elicit information specific to the attacks that occur with this disorder? A. “Are you having any headaches?” B. “Do you have difficulty speaking?” C. “Do you have a feeling of fullness in your ear?” Correct D. “Do you have momentary losses of consciousness?”
Rationale: Meniere’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus. Headaches, difficulty speaking, and momentary losses of consciousness are not associated with this disorder.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology associated with Meniere’s disease to answer this question. Recalling that this disorder is associated with the ear will direct you to the correct option. If you are unfamiliar with Meniere’s disease, review this content.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Adult Health/Ear
Giddens Concepts: Clinical Judgment, Intracranial Regulation
HESI Concepts: Assessment, Intracranial Regulation
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 405-406). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
17.ID: 6
A nurse provides discharge instructions to a client who was hospitalized for an acute attack of Meniere’s disease. Which statements by the nurse are correct? Select all that apply. A. Unrestricted salt is allowed in the diet. B. Position changes should be made slowly. Correct C. Underwater swimming should be avoided. Correct D. It is best to switch to decaffeinated tea and coffee. Correct E. A glass of red wine in the evening will ease symptoms. F. If an acute attack occurs, sit down and keep the eyes closed. Correct
Rationale: Meniere’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. If an acute attack of vertigo occurs, the client is instructed to immediately lie down on a firm surface if possible, loosen clothing, and close the eyes until the acute vertigo stops. Between attacks, the client may resume normal activities but should avoid underwater swimming, which may cause a loss of orientation. The nurse encourages the client to follow a low-salt diet and to avoid excessive use of caffeine, sugar, monosodium glutamate, and alcohol. The client should be taught to avoid sudden head movements or position changes.
Test-Taking Strategy: Use the process of elimination. Recalling that Meniere’s disease is an ear disorder and that it occurs as a result of a disturbance in the fluid of the endolymphatic system will direct you to correct options. If you are unfamiliar with the management of Meniere’s disease, review this content.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Ear
Giddens Concepts: Client Education, Intracranial Regulation
HESI Concepts: Intracranial Regulation, Teaching and Learning/Patient Education
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. ). St. Louis: Saunders.
~ Rationale: Meniere’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. If an acute attack of vertigo occurs, the client is instructed to immediately lie down on a firm surface if possible, loosen clothing, and close the eyes until the acute vertigo stops. Between attacks, the client may resume normal activities but should avoid underwater swimming, which may cause a loss of orientation. The nurse encourages the client to follow a low-salt diet and to avoid excessive use of caffeine, sugar, monosodium glutamate, and alcohol. The client should be taught to avoid sudden head movements or position changes.
Test-Taking Strategy: Use the process of elimination. Recalling that Meniere’s disease is an ear disorder and that it occurs as a result of a disturbance in the fluid of the endolymphatic system will direct you to correct options. If you are unfamiliar with the management of Meniere’s disease, review this content.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Ear
Giddens Concepts: Client Education, Intracranial Regulation
HESI Concepts: Intracranial Regulation, Teaching and Learning/Patient Education
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. ). St. Louis: Saunders.
Awarded 3.0 points out of 4.0 possible points.
18.ID: 7
A client arrives at the emergency department and reports a buzzing sound in his ear. The client tells the nurse that an insect flew into the ear. Which intervention does the nurse take first to remove the insect? A. Instilling antibiotic eardrops Incorrect B. Instilling lidocaine into the ear Correct C. Using ear forceps to remove the insect D. Irrigating the ear with sterile saline solution
Rationale: Insects that make their way into an ear are killed before removal unless they can be coaxed out with the use of a flashlight or a humming noise. Mineral oil, diluted alcohol, or lidocaine (not water) is instilled into the ear canal (or an ether-soaked cotton ball is placed in the ear) to suffocate the insect, which is then removed with the use of ear forceps. When the foreign object is vegetable matter, irrigation is not used, because this material expands with hydration, worsening the impaction becomes worse. Antibiotics may or may not be prescribed after removal of the insect.
Test-Taking Strategy: Use the process of elimination and your knowledge regarding care of the client with a foreign body in the ear to answer this question. Note the strategic word “first,” which should direct you to the correct option. If you had difficulty with this question, review care of the client with a foreign body in the ear.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Ear
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 403). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
19.ID: 2
A home care nurse, assessing the skin of a client, notes the following rash beneath the skin:

Which precaution will the nurse immediately institute before completing the assessment? A. Donning a mask and gloves B. Putting on a gown and gloves Correct C. Putting on a head covering and gloves D. E. F. Avoiding sitting on the client’s furniture G.
Rationale: Scabies presents as vesicle or pustule irritations, burrows, or rash of the skin, especially in the webbing between the fingers. When a client is infested with scabies, a gown and gloves should be worn for close contact. A mask and head covering are not necessary. Transmission by way of clothing and other inanimate objects is uncommon. Scabies is usually transmitted from person to person by way of direct skin contact. All of the client’s contacts should be treated for the infestation at the same time.
Test-Taking Strategy: Remember the typical appearance of the scabies rash, then consider the mode of transmission of scabies and use the process of elimination. Because scabies is transmitted by way of direct skin contact, select the gown and gloves. If you had difficulty with this question, review the customary appearance of a scabies rash, standard precautions, and the mode of transmission of scabies.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Giddens Concepts: Infection, Tissue Integrity
HESI Concepts: Infection, Tissue Integrity
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 440-441). St. Louis: Saunders.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 437). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.