Focus on Adult Health Exam 2023 Updated Questions and
Answers Correct
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
Answers Correct
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
