Focus on Adult Health Exam Test Questions with Answers Graded A+
Tall T waves
Prolonged PR interval
Hyperactive bowel sounds
Rationale: Spironolactone is a potassium-sparing diuretic.
Potassium-sparing diuretics can cause hyperkalemia. Car-
A nurse is monitoring a client who is taking spironolactone diovascular manifestations of hyperkalemia include tall T
for the treatment of hypertension. Which findings denote waves, widened QRS complexes, prolonged PR intervals,
adverse ettects of the medication? Select all that apply. and flat P waves. Other cardiovascular manifestations in-
clude an irregular heart rate, decreased blood pressure,
and ectopic heartbeats. Muscle twitches occur in hyper-
kalemia. Hyperactive bowel sounds and diarrhea also oc-
cur in hyperkalemia. Constipation, hyporeflexia, and shal-
low respirations are signs of hypokalemia.
Avoid drinking fluids before and during meals
Select foods that are easy to chew and are not gas form-
ing
Rationale: COPD is a progressive and irreversible condition
characterized by diminished inspiratory and expiratory
A nurse is providing dietary instructions to a client with capacity of the lungs. Instruct the client who complains
chronic obstructive pulmonary disease (COPD) who is ex- of feeling too full to eat, to avoid drinking fluids before
periencing a loss of appetite and complains of feeling "too and during the meal. Dry foods such as crackers stimulate
full to eat." What does the nurse encourage the client to coughing; foods such as milk and chocolate may increase
do? Select all that apply. the thickness of saliva and secretions. Cheese is constipat-
ing 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).
,Focus on Adult Health Exam Test Questions with Answers Graded A+
Positive
Rationale: The tuberculin, or TST, test is a reliable determi-
nant 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-immuno-
suppressed 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.
14 cm H2O
Rationale: CVP measurements are used to monitor blood
volume and the adequacy of venous return to the heart.
A nurse is interpreting a central venous pressure (CVP)
The CVP measures pressures from the right atrium or cen-
reading from a client in whom right ventricular failure has
tral veins. The normal CVP is 7 to 12 cm H2O. An increased
been diagnosed. From this diagnosis, the nurse would
CVP reading may indicate right ventricular failure. A low
expect that the most likely result is a pressure of
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.
Checking for moisture on the back of the dressing over the
client's neck and shoulders
Rationale: Thyroid surgery may be complicated by he-
morrhage, respiratory distress, parathyroid gland injury
A nurse is caring for a client who has just undergone (resulting in hypocalcemia and tetany), damage to the
thyroidectomy. Which technique is the best way for the laryngeal nerves, and thyroid storm. Hemorrhage is most
nurse to assess the surgical site for bleeding? 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 under-
lying 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.
Whole-milk shake and granola
Baked potato topped with cheese
Cheese and whole-wheat crackers
Rationale: To facilitate healing and meet continued high
metabolic needs, the client with a major burn should
A client who sustained a major burn injury is beginning
eat a diet high in calories, protein, and carbohydrates.
to take an oral diet again. Which between-meal menu
This type of diet also keeps the client in positive nitrogen
selections meet the client's needs for wound healing and
balance. Foods such as milkshakes, granola, cheese, and
tissue repair? Select all that apply.
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.
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
A client is found to have hypoparathyroidism. Which nu- phosphate levels and should consume a diet high in cal-
tritional supplement does the nurse, teaching the client cium but low in phosphorus. Additionally, the generally
about measures to manage the disorder, tell the client to used treatment is calcium supplementation (either as cal-
take on a daily basis? cium carbonate or calcium citrate) coupled with vitamin
D supplementation. Vitamin C supplementation is not a
treatment measure for this disorder. Beta-carotene is in-
correct, 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
, 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 glu-
cose 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.
Chest pain
Palpitations
Rapid heart rate
Rationale: The client taking levothyroxine sodium may
have manifestations of hypothyroidism if the dosage is
Levothyroxine sodium is prescribed for a client with hy-
inadequate or may experience manifestations of hyper-
pothyroidism, and the nurse provides information to the
thyroidism if the dosage is too high. Thyroid preparations
client about the medication. Which occurrences does the
increase metabolic rate, oxygen demands, and demands
nurse tell the client to report to the health care provider?
on the heart, which may result in angina and cardiac
Select all that apply.
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).
Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower
A nurse is developing a plan of care for an older client
extremities has a diminished sensation in the legs and
with diabetic neuropathy of the lower extremities resulting
feet. This client is at risk for tissue injury and for falls
as a result of this nervous system impairment. Therefore
Tall T waves
Prolonged PR interval
Hyperactive bowel sounds
Rationale: Spironolactone is a potassium-sparing diuretic.
Potassium-sparing diuretics can cause hyperkalemia. Car-
A nurse is monitoring a client who is taking spironolactone diovascular manifestations of hyperkalemia include tall T
for the treatment of hypertension. Which findings denote waves, widened QRS complexes, prolonged PR intervals,
adverse ettects of the medication? Select all that apply. and flat P waves. Other cardiovascular manifestations in-
clude an irregular heart rate, decreased blood pressure,
and ectopic heartbeats. Muscle twitches occur in hyper-
kalemia. Hyperactive bowel sounds and diarrhea also oc-
cur in hyperkalemia. Constipation, hyporeflexia, and shal-
low respirations are signs of hypokalemia.
Avoid drinking fluids before and during meals
Select foods that are easy to chew and are not gas form-
ing
Rationale: COPD is a progressive and irreversible condition
characterized by diminished inspiratory and expiratory
A nurse is providing dietary instructions to a client with capacity of the lungs. Instruct the client who complains
chronic obstructive pulmonary disease (COPD) who is ex- of feeling too full to eat, to avoid drinking fluids before
periencing a loss of appetite and complains of feeling "too and during the meal. Dry foods such as crackers stimulate
full to eat." What does the nurse encourage the client to coughing; foods such as milk and chocolate may increase
do? Select all that apply. the thickness of saliva and secretions. Cheese is constipat-
ing 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).
,Focus on Adult Health Exam Test Questions with Answers Graded A+
Positive
Rationale: The tuberculin, or TST, test is a reliable determi-
nant 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-immuno-
suppressed 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.
14 cm H2O
Rationale: CVP measurements are used to monitor blood
volume and the adequacy of venous return to the heart.
A nurse is interpreting a central venous pressure (CVP)
The CVP measures pressures from the right atrium or cen-
reading from a client in whom right ventricular failure has
tral veins. The normal CVP is 7 to 12 cm H2O. An increased
been diagnosed. From this diagnosis, the nurse would
CVP reading may indicate right ventricular failure. A low
expect that the most likely result is a pressure of
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.
Checking for moisture on the back of the dressing over the
client's neck and shoulders
Rationale: Thyroid surgery may be complicated by he-
morrhage, respiratory distress, parathyroid gland injury
A nurse is caring for a client who has just undergone (resulting in hypocalcemia and tetany), damage to the
thyroidectomy. Which technique is the best way for the laryngeal nerves, and thyroid storm. Hemorrhage is most
nurse to assess the surgical site for bleeding? 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 under-
lying 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.
Whole-milk shake and granola
Baked potato topped with cheese
Cheese and whole-wheat crackers
Rationale: To facilitate healing and meet continued high
metabolic needs, the client with a major burn should
A client who sustained a major burn injury is beginning
eat a diet high in calories, protein, and carbohydrates.
to take an oral diet again. Which between-meal menu
This type of diet also keeps the client in positive nitrogen
selections meet the client's needs for wound healing and
balance. Foods such as milkshakes, granola, cheese, and
tissue repair? Select all that apply.
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.
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
A client is found to have hypoparathyroidism. Which nu- phosphate levels and should consume a diet high in cal-
tritional supplement does the nurse, teaching the client cium but low in phosphorus. Additionally, the generally
about measures to manage the disorder, tell the client to used treatment is calcium supplementation (either as cal-
take on a daily basis? cium carbonate or calcium citrate) coupled with vitamin
D supplementation. Vitamin C supplementation is not a
treatment measure for this disorder. Beta-carotene is in-
correct, 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
, 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 glu-
cose 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.
Chest pain
Palpitations
Rapid heart rate
Rationale: The client taking levothyroxine sodium may
have manifestations of hypothyroidism if the dosage is
Levothyroxine sodium is prescribed for a client with hy-
inadequate or may experience manifestations of hyper-
pothyroidism, and the nurse provides information to the
thyroidism if the dosage is too high. Thyroid preparations
client about the medication. Which occurrences does the
increase metabolic rate, oxygen demands, and demands
nurse tell the client to report to the health care provider?
on the heart, which may result in angina and cardiac
Select all that apply.
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).
Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower
A nurse is developing a plan of care for an older client
extremities has a diminished sensation in the legs and
with diabetic neuropathy of the lower extremities resulting
feet. This client is at risk for tissue injury and for falls
as a result of this nervous system impairment. Therefore
