Focus on Adult Health Exam 2023 Questions and Answers
100% Verified
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.
Tall T waves
Prolonged PR interval
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.
Avoid drinking fluids before and during meals
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
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 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?
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 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.
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 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 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?
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?
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.
Chest pain
Palpitations
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).
A nurse is developing a plan of care for an older client with diabetic neuropathy of the
lower extremities resulting from type 2 diabetes mellitus. Which problem does the nurse
recognize as the highest priority for this client?
Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower extremities has a diminished
sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of this
nervous system impairment. Therefore the highest priority nursing problem is increased risk for
injury. Increased risk of depression and change in body image are more psychosocial in nature
and, as such, are secondary needs. A lower level of physical activity may be a problem but is not
the priority.
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.
Shakiness
Blurred vision
Feelings of hunger
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
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
It does not have a peak effect.
It is usually given once daily, at bedtime.
It usually has a 24-hour duration of action
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.
100% Verified
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.
Tall T waves
Prolonged PR interval
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.
Avoid drinking fluids before and during meals
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
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 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?
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 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.
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 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 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?
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?
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.
Chest pain
Palpitations
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).
A nurse is developing a plan of care for an older client with diabetic neuropathy of the
lower extremities resulting from type 2 diabetes mellitus. Which problem does the nurse
recognize as the highest priority for this client?
Increased risk for injury
Rationale: The client with diabetic neuropathy of the lower extremities has a diminished
sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of this
nervous system impairment. Therefore the highest priority nursing problem is increased risk for
injury. Increased risk of depression and change in body image are more psychosocial in nature
and, as such, are secondary needs. A lower level of physical activity may be a problem but is not
the priority.
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.
Shakiness
Blurred vision
Feelings of hunger
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
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
It does not have a peak effect.
It is usually given once daily, at bedtime.
It usually has a 24-hour duration of action
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.
