Advanced Adult Health Exam 1 practice
questions
1. |On |a |hot |humid |day, |an |emergency |department |nurse |is |caring |for |a |client |who |is |confused |
and |has |these |vital |signs: |temperature |104.1° |F |(40.1° |C), |pulse |132 |beats/min, |respirations |26
|breaths/min, |blood |pressure |106/66 |mm |Hg. |Which |action |should |the |nurse |take?
a. |Encourage |the |client |to |drink |cool |water |or |sports |drinks.
b. |Start |an |intravenous |line |and |infuse |0.9% |saline |solution.
c. |Administer |acetaminophen |(Tylenol) |650 |mg |orally.
d. |Encourage |rest |and |re-assess |in |15 |minutes. |- |CORRECT |ANSWER✔✔-ANS: |B
The |client |demonstrates |signs |of |heat |stroke. |This |is |a |medical |emergency |and |priority |care |
includes |oxygen |therapy, |IV |infusion |with |0.9% |saline |solution, |insertion |of |a |urinary |catheter, |
and |aggressive |interventions |to |cool |the |client, |including |external |cooling |and |internal |cooling |
methods. |Oral |hydration |would |not |be |appropriate |for |a |client |who |has |symptoms |of |heat |
stroke |because |oral |fluids |would |not |provide |necessary |rapid |rehydration, |and |the |confused |
client |would |be |at |risk |for |aspiration. |Acetaminophen |would |not |decrease |this |client's |
temperature |or |improve |the |client's |symptoms. |The |client |needs |immediate |medical |
treatment; |therefore, |rest |and |re-assessing |in |15 |minutes |is |inappropriate.
2. |While |at |a |public |park, |a |nurse |encounters |a |person |immediately |after |a |bee |sting. |The |
person's |lips |are |swollen, |and |wheezes |are |audible. |Which |action |should |the |nurse |take |first?
a. |Elevate |the |site |and |notify |the |person's |next |of |kin.
b. |Remove |the |stinger |with |tweezers |and |encourage |rest.
c. |Administer |diphenhydramine |(Benadryl) |and |apply |ice.
d. |Administer |an |EpiPen |from |the |first |aid |kit |and |call |911. |- |CORRECT |ANSWER✔✔-ANS: |D
The |client's |swollen |lips |indicate |that |anaphylaxis |may |be |developing, |and |this |is |a |medical |
emergency. |911 |should |be |called |immediately, |and |the |client |transported |to |the |emergency |
department |as |quickly |as |possible. |If |an |EpiPen |is |available, |it |should |be |administered |at |the |
,first |sign |of |an |anaphylactic |reaction. |The |other |answers |do |not |provide |adequate |
interventions |to |treat |airway |obstruction |due |to |anaphylaxis.
3. |A |client |presents |to |the |emergency |department |after |prolonged |exposure |to |the |cold. |The |
client |is |difficult |to |arouse |and |speech |is |incoherent. |Which |action |should |the |nurse |take |first?
a. |Reposition |the |client |into |a |prone |position.
b. |Administer |warmed |intravenous |fluids |to |the |client.
c. |Wrap |the |client's |extremities |in |warm |blankets.
d. |Initiate |extracorporeal |rewarming |via |hemodialysis. |- |CORRECT |ANSWER✔✔-ANS: |B
Moderate |hypothermia |manifests |with |muscle |weakness, |increased |loss |of |coordination, |acute
|confusion, |apathy, |incoherence, |stupor, |and |impaired |clotting. |Moderate |hypothermia |should |
be |treated |by |core |rewarming |methods, |which |include |administration |of |warm |IV |fluids, |
heated |oxygen, |and |heated |peritoneal, |pleural, |gastric, |or |bladder |lavage, |and |by |positioning |
the |client |in |a |supine |position |to |prevent |orthostatic |changes. |The |client's |trunk |should |be |
warmed |prior |to |the |extremities |to |prevent |peripheral |vasodilation. |Extracorporeal |warming |
with |cardiopulmonary |bypass |or |hemodialysis |is |a |treatment |for |severe |hypothermia.
4. |An |emergency |department |nurse |cares |for |a |middle-aged |mountain |climber |who |is |
confused |and |exhibits |bizarre |behaviors. |After |administering |oxygen, |which |priority |
intervention |should |the |nurse |implement?
a. |Administer |dexamethasone |(Decadron).
b. |Complete |a |mini-mental |state |examination.
c. |Prepare |the |client |for |computed |tomography |of |the |brain.
d. |Request |a |psychiatric |consult. |- |CORRECT |ANSWER✔✔-ANS: |A
The |client |is |exhibiting |signs |of |mountain |sickness |and |high |altitude |cerebral |edema |(HACE). |
Dexamethasone |(Decadron) |reduces |cerebral |edema |by |acting |as |an |anti-inflammatory |in |the |
central |nervous |system. |The |other |interventions |will |not |treat |mountain |sickness |or |HACE.
5. |An |emergency |department |nurse |assesses |a |client |admitted |after |a |lightning |strike. |Which |
assessment |should |the |nurse |complete |first?
, a. |Electrocardiogram |(ECG)
b. |Wound |inspection
c. |Creatinine |kinase
d. |Computed |tomography |of |head |- |CORRECT |ANSWER✔✔-ANS: |A
Clients |who |survive |an |immediate |lightning |strike |can |have |serious |myocardial |injury, |which |
can |be |manifested |by |ECG |and |myocardial |perfusion |abnormalities. |The |nurse |should |prioritize
|the |ECG. |Other |assessments |should |be |completed |but |are |not |the |priority.
6. |A |nurse |teaches |a |community |health |class |about |water |safety. |Which |statement |by |a |
participant |indicates |that |additional |teaching |is |needed?
a. |"I |can |go |swimming |all |by |myself |because |I |am |a |certified |lifeguard."
b. |"I |cannot |leave |my |toddler |alone |in |the |bathtub |for |even |a |minute."
c. |"I |will |appoint |one |adult |to |supervise |the |pool |at |all |times |during |a |party."
d. |"I |will |make |sure |that |there |is |a |phone |near |my |pool |in |case |of |an |emergency." |- |CORRECT |
ANSWER✔✔-ANS: |A
People |should |never |swim |alone, |regardless |of |lifeguard |status. |The |other |statements |indicate |
good |understanding |of |the |teaching.
7. |A |provider |prescribes |a |rewarming |bath |for |a |client |who |presents |with |partial-thickness |
frostbite. |Which |action |should |the |nurse |take |prior |to |starting |this |treatment?
a. |Administer |intravenous |morphine.
b. |Wrap |the |limb |with |a |compression |dressing.
c. |Massage |the |frostbitten |areas.
d. |Assess |the |limb |for |compartment |syndrome. |- |CORRECT |ANSWER✔✔-ANS: |A
Rapid |rewarming |in |a |water |bath |is |recommended |for |all |instances |of |partial-thickness |and |
full-thickness |frostbite. |Clients |experience |severe |pain |during |the |rewarming |process |and |
nurses |should |administer |intravenous |analgesics.
questions
1. |On |a |hot |humid |day, |an |emergency |department |nurse |is |caring |for |a |client |who |is |confused |
and |has |these |vital |signs: |temperature |104.1° |F |(40.1° |C), |pulse |132 |beats/min, |respirations |26
|breaths/min, |blood |pressure |106/66 |mm |Hg. |Which |action |should |the |nurse |take?
a. |Encourage |the |client |to |drink |cool |water |or |sports |drinks.
b. |Start |an |intravenous |line |and |infuse |0.9% |saline |solution.
c. |Administer |acetaminophen |(Tylenol) |650 |mg |orally.
d. |Encourage |rest |and |re-assess |in |15 |minutes. |- |CORRECT |ANSWER✔✔-ANS: |B
The |client |demonstrates |signs |of |heat |stroke. |This |is |a |medical |emergency |and |priority |care |
includes |oxygen |therapy, |IV |infusion |with |0.9% |saline |solution, |insertion |of |a |urinary |catheter, |
and |aggressive |interventions |to |cool |the |client, |including |external |cooling |and |internal |cooling |
methods. |Oral |hydration |would |not |be |appropriate |for |a |client |who |has |symptoms |of |heat |
stroke |because |oral |fluids |would |not |provide |necessary |rapid |rehydration, |and |the |confused |
client |would |be |at |risk |for |aspiration. |Acetaminophen |would |not |decrease |this |client's |
temperature |or |improve |the |client's |symptoms. |The |client |needs |immediate |medical |
treatment; |therefore, |rest |and |re-assessing |in |15 |minutes |is |inappropriate.
2. |While |at |a |public |park, |a |nurse |encounters |a |person |immediately |after |a |bee |sting. |The |
person's |lips |are |swollen, |and |wheezes |are |audible. |Which |action |should |the |nurse |take |first?
a. |Elevate |the |site |and |notify |the |person's |next |of |kin.
b. |Remove |the |stinger |with |tweezers |and |encourage |rest.
c. |Administer |diphenhydramine |(Benadryl) |and |apply |ice.
d. |Administer |an |EpiPen |from |the |first |aid |kit |and |call |911. |- |CORRECT |ANSWER✔✔-ANS: |D
The |client's |swollen |lips |indicate |that |anaphylaxis |may |be |developing, |and |this |is |a |medical |
emergency. |911 |should |be |called |immediately, |and |the |client |transported |to |the |emergency |
department |as |quickly |as |possible. |If |an |EpiPen |is |available, |it |should |be |administered |at |the |
,first |sign |of |an |anaphylactic |reaction. |The |other |answers |do |not |provide |adequate |
interventions |to |treat |airway |obstruction |due |to |anaphylaxis.
3. |A |client |presents |to |the |emergency |department |after |prolonged |exposure |to |the |cold. |The |
client |is |difficult |to |arouse |and |speech |is |incoherent. |Which |action |should |the |nurse |take |first?
a. |Reposition |the |client |into |a |prone |position.
b. |Administer |warmed |intravenous |fluids |to |the |client.
c. |Wrap |the |client's |extremities |in |warm |blankets.
d. |Initiate |extracorporeal |rewarming |via |hemodialysis. |- |CORRECT |ANSWER✔✔-ANS: |B
Moderate |hypothermia |manifests |with |muscle |weakness, |increased |loss |of |coordination, |acute
|confusion, |apathy, |incoherence, |stupor, |and |impaired |clotting. |Moderate |hypothermia |should |
be |treated |by |core |rewarming |methods, |which |include |administration |of |warm |IV |fluids, |
heated |oxygen, |and |heated |peritoneal, |pleural, |gastric, |or |bladder |lavage, |and |by |positioning |
the |client |in |a |supine |position |to |prevent |orthostatic |changes. |The |client's |trunk |should |be |
warmed |prior |to |the |extremities |to |prevent |peripheral |vasodilation. |Extracorporeal |warming |
with |cardiopulmonary |bypass |or |hemodialysis |is |a |treatment |for |severe |hypothermia.
4. |An |emergency |department |nurse |cares |for |a |middle-aged |mountain |climber |who |is |
confused |and |exhibits |bizarre |behaviors. |After |administering |oxygen, |which |priority |
intervention |should |the |nurse |implement?
a. |Administer |dexamethasone |(Decadron).
b. |Complete |a |mini-mental |state |examination.
c. |Prepare |the |client |for |computed |tomography |of |the |brain.
d. |Request |a |psychiatric |consult. |- |CORRECT |ANSWER✔✔-ANS: |A
The |client |is |exhibiting |signs |of |mountain |sickness |and |high |altitude |cerebral |edema |(HACE). |
Dexamethasone |(Decadron) |reduces |cerebral |edema |by |acting |as |an |anti-inflammatory |in |the |
central |nervous |system. |The |other |interventions |will |not |treat |mountain |sickness |or |HACE.
5. |An |emergency |department |nurse |assesses |a |client |admitted |after |a |lightning |strike. |Which |
assessment |should |the |nurse |complete |first?
, a. |Electrocardiogram |(ECG)
b. |Wound |inspection
c. |Creatinine |kinase
d. |Computed |tomography |of |head |- |CORRECT |ANSWER✔✔-ANS: |A
Clients |who |survive |an |immediate |lightning |strike |can |have |serious |myocardial |injury, |which |
can |be |manifested |by |ECG |and |myocardial |perfusion |abnormalities. |The |nurse |should |prioritize
|the |ECG. |Other |assessments |should |be |completed |but |are |not |the |priority.
6. |A |nurse |teaches |a |community |health |class |about |water |safety. |Which |statement |by |a |
participant |indicates |that |additional |teaching |is |needed?
a. |"I |can |go |swimming |all |by |myself |because |I |am |a |certified |lifeguard."
b. |"I |cannot |leave |my |toddler |alone |in |the |bathtub |for |even |a |minute."
c. |"I |will |appoint |one |adult |to |supervise |the |pool |at |all |times |during |a |party."
d. |"I |will |make |sure |that |there |is |a |phone |near |my |pool |in |case |of |an |emergency." |- |CORRECT |
ANSWER✔✔-ANS: |A
People |should |never |swim |alone, |regardless |of |lifeguard |status. |The |other |statements |indicate |
good |understanding |of |the |teaching.
7. |A |provider |prescribes |a |rewarming |bath |for |a |client |who |presents |with |partial-thickness |
frostbite. |Which |action |should |the |nurse |take |prior |to |starting |this |treatment?
a. |Administer |intravenous |morphine.
b. |Wrap |the |limb |with |a |compression |dressing.
c. |Massage |the |frostbitten |areas.
d. |Assess |the |limb |for |compartment |syndrome. |- |CORRECT |ANSWER✔✔-ANS: |A
Rapid |rewarming |in |a |water |bath |is |recommended |for |all |instances |of |partial-thickness |and |
full-thickness |frostbite. |Clients |experience |severe |pain |during |the |rewarming |process |and |
nurses |should |administer |intravenous |analgesics.
