Advanced Adult Health Exam. Chapter 1
- Mental Health and Illness, Chap 2-
biological implications, Chapter 3:
Ethical and Legal Issues
The nurse is administering a transfusion of packed red blood cells to the client intervention should the
nurse implement list in order of performance - Verify the client has signed the consent, Assess the IV
site for size and patency, Obtain the blood from the laboratory, Check the blood with another nurse at
the bedside, Start the transfusion slowly
A nurse is caring for a client who has emphysema which of the following findings with the nurse not
expect to assess in this client? - deep respirations
Client has a nasogastric tube following a subtotal gastrectomy the nurse should? - Reposition the tube if
it is not draining well
The client in the medical unit begins to experience a severe anaphylactic reaction after the initial dose of
IV penicillin an antibiotic which intervention would be least likely implemented as immediate response
to this development - Request and obtain a routine chest x-ray
A client was admitted following a motor vehicle accident the nurse notes the client has a Glasgow coma
scale score of three what should the nurses primary concern - protect airway
A nurse is admitting a client who has influenza accompanied by severe nausea and vomiting client
reports numbness and tingling of the toes and fingers the nurse should recognize a client is experiencing
which of the following Acid base imbalances? - Metabolic alkalosis
The nurse assesses the client stoma during the initial post operative. Which of the following
observations should be reported immediately to the physician? - The stoma is dark red to purple
,A client with a history of angina Pectoris is admitted to the medical surgical unit for treatment of peptic
ulcer ration after lunch the client calls the nearest airports an 8/10 crushing pain in his chest the nurses
first action is? - administer nitrates and aspirin as ordered
Which of the following interventions may prevent a urinary track infection? - drink cranberry juice
What does the following statements is true regarding the difference between diabetic ketoacidosis and
hyperglycemic hyperosmolar syndrome? - HHS develops over the course of days while DKA has a rapid
onset
Which of the following clients is most at risk for developing a deep vein thrombosis? - 40 year old who
smokes and uses oral contraceptives
A nurse is caring for a client who is using a patient controlled analgesia Pump for a postoperative pain
management the nurse enters the room and find the client asleep and his wife pressing the button to
dispense another dose which of the following responses should the nurse make? - Only your husband
should decide when more medication is needed
A client has a complaint of incontinent episode 20 sneezing coughing laughing or changing body
positions which type of incontinence should the nurse document in the EMR? - Stress
The nurses forearm is spotted with blood while inserting an intravenous catheter which action should
the nurse take? - wash with soap and water
A nurse is assessing a client who has developed atelectasis postoperatively which of the following
findings should the nurse expect? - Increased dyspnea
A nurse discovers a client suicide note that details the time place and needs to commit suicide what
should be the priority nursing intervention and the rationale for this action? - Placing this client on one-
to-one suicide precautions, because the more specific the plan, the more likely the client will attempt
suicide
,A client on an impatient psychiatric unit angrily says to a nurse Peter is not cleaning up after himself in
the community bathroom you need to address this problem which is the appropriate nursing response?
- I can see that you are angry. Let's discuss ways to approach Peter with your concerns.
A nurse is admitting a client who has a newly applied Fiberglass cast for a fractured tibia what does the
following is a priority action for the nurse to take? - Preform a neurovascular assessment
A client is undergoing assessment of cranial nerve VIII it's likely to have which of the following included
in his examination? - weber, rinse and Romberg test
A nurse is caring for a client recently diagnosed with hypothyroidism the client has thinning of her hair
and a change in her bowel movements from every day to once every other day she also reports a new
preference for warmer environments and profound decrease to her energy levels which of the following
nursing diagnoses would be the priority for this client? - Body image disturbed related to physical
changes
A patient has been brought to the emergency department with multiple trauma after a MVA. After
immediate threats to life have been corrrected in a patient with multiple trauma, which action would
the nurse perform? - Perform a rapid physical assessment
A patient has been admitted to your unit with a GI ulcer. The patient/client is NPO and has a nasogastric
tube in place connected to low suction. What for of shock should you monitor this patient for? -
Hypovolemic shock
A patient diagnosed with borderline personality disorder coyly requests diazepam (valium). When the
physician refuses, the client becomes angry and demands to see another physician. What defense
mechanism is the patient/client using? - Splitting
A patient with mitral valve stenosis is admitted to your unit. She is scheduled for surgery to repair her
valve. What procedure is usually performed to open the mitral valve? - Commissurotomy
, A patient who underwent a lobectomy and has a water-seal chest drainage system is breathing with a
little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increase. The nurse
should? - Check the tubing to ensure that it is not kinked or that an air leak is present.
A patient with high anxiety asks the nurse to take per pulse and listen to her heart several times an hour.
What is the best way for the nurse to cope with this situation? - Show understanding of the client's
needs by jointly setting up a two hour schedule to monitor her pulse and heart rate.
A 44-year-old male patient has been exposed to a severe amount of radiation after a leak in a reactor
plant. When planning this patient's care, the nurse should implement what action? - The patient should
be carefully protected from infection.
The newly admitted patient has burns on both legs. The burned areas appear white and leather-like. No
blisters or bleeding are present, and the patient states that he has little pain. How should you categorize
this injury? - Full-thickness
What is the rationale for administering tissue plasminogen activator (t-PA) within 3 hours of a
thrombotic stroke? - To cause fibrinolysis of the clot
The male patient with a C-6 spinal cord injury (SCI) tells the home health nurse he has had a severe
pounding headache for the last 2 hours. Which intervention should the home health nurse implement? -
Determine when the patient last urinated.
The nurse is caring for a female patient who sustained a closed head injury 8 days ago due to a motor
vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury? -
The patient tells the nurse she has a stuffy nose and green nasal discharge
A patient is admitted to the hospital with a head injury resulting from an automobile accident. On
admission the patient/clients vital signs are temperature 98.6 F (37 C), blood pressure 128/68, pulse
110, and respirations 26. One hour after admission, the nurse notes the presence of the Cushing's triad
when the patient's vital signs are - Blood pressure 156/60, pulse 60, respirations 14
- Mental Health and Illness, Chap 2-
biological implications, Chapter 3:
Ethical and Legal Issues
The nurse is administering a transfusion of packed red blood cells to the client intervention should the
nurse implement list in order of performance - Verify the client has signed the consent, Assess the IV
site for size and patency, Obtain the blood from the laboratory, Check the blood with another nurse at
the bedside, Start the transfusion slowly
A nurse is caring for a client who has emphysema which of the following findings with the nurse not
expect to assess in this client? - deep respirations
Client has a nasogastric tube following a subtotal gastrectomy the nurse should? - Reposition the tube if
it is not draining well
The client in the medical unit begins to experience a severe anaphylactic reaction after the initial dose of
IV penicillin an antibiotic which intervention would be least likely implemented as immediate response
to this development - Request and obtain a routine chest x-ray
A client was admitted following a motor vehicle accident the nurse notes the client has a Glasgow coma
scale score of three what should the nurses primary concern - protect airway
A nurse is admitting a client who has influenza accompanied by severe nausea and vomiting client
reports numbness and tingling of the toes and fingers the nurse should recognize a client is experiencing
which of the following Acid base imbalances? - Metabolic alkalosis
The nurse assesses the client stoma during the initial post operative. Which of the following
observations should be reported immediately to the physician? - The stoma is dark red to purple
,A client with a history of angina Pectoris is admitted to the medical surgical unit for treatment of peptic
ulcer ration after lunch the client calls the nearest airports an 8/10 crushing pain in his chest the nurses
first action is? - administer nitrates and aspirin as ordered
Which of the following interventions may prevent a urinary track infection? - drink cranberry juice
What does the following statements is true regarding the difference between diabetic ketoacidosis and
hyperglycemic hyperosmolar syndrome? - HHS develops over the course of days while DKA has a rapid
onset
Which of the following clients is most at risk for developing a deep vein thrombosis? - 40 year old who
smokes and uses oral contraceptives
A nurse is caring for a client who is using a patient controlled analgesia Pump for a postoperative pain
management the nurse enters the room and find the client asleep and his wife pressing the button to
dispense another dose which of the following responses should the nurse make? - Only your husband
should decide when more medication is needed
A client has a complaint of incontinent episode 20 sneezing coughing laughing or changing body
positions which type of incontinence should the nurse document in the EMR? - Stress
The nurses forearm is spotted with blood while inserting an intravenous catheter which action should
the nurse take? - wash with soap and water
A nurse is assessing a client who has developed atelectasis postoperatively which of the following
findings should the nurse expect? - Increased dyspnea
A nurse discovers a client suicide note that details the time place and needs to commit suicide what
should be the priority nursing intervention and the rationale for this action? - Placing this client on one-
to-one suicide precautions, because the more specific the plan, the more likely the client will attempt
suicide
,A client on an impatient psychiatric unit angrily says to a nurse Peter is not cleaning up after himself in
the community bathroom you need to address this problem which is the appropriate nursing response?
- I can see that you are angry. Let's discuss ways to approach Peter with your concerns.
A nurse is admitting a client who has a newly applied Fiberglass cast for a fractured tibia what does the
following is a priority action for the nurse to take? - Preform a neurovascular assessment
A client is undergoing assessment of cranial nerve VIII it's likely to have which of the following included
in his examination? - weber, rinse and Romberg test
A nurse is caring for a client recently diagnosed with hypothyroidism the client has thinning of her hair
and a change in her bowel movements from every day to once every other day she also reports a new
preference for warmer environments and profound decrease to her energy levels which of the following
nursing diagnoses would be the priority for this client? - Body image disturbed related to physical
changes
A patient has been brought to the emergency department with multiple trauma after a MVA. After
immediate threats to life have been corrrected in a patient with multiple trauma, which action would
the nurse perform? - Perform a rapid physical assessment
A patient has been admitted to your unit with a GI ulcer. The patient/client is NPO and has a nasogastric
tube in place connected to low suction. What for of shock should you monitor this patient for? -
Hypovolemic shock
A patient diagnosed with borderline personality disorder coyly requests diazepam (valium). When the
physician refuses, the client becomes angry and demands to see another physician. What defense
mechanism is the patient/client using? - Splitting
A patient with mitral valve stenosis is admitted to your unit. She is scheduled for surgery to repair her
valve. What procedure is usually performed to open the mitral valve? - Commissurotomy
, A patient who underwent a lobectomy and has a water-seal chest drainage system is breathing with a
little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increase. The nurse
should? - Check the tubing to ensure that it is not kinked or that an air leak is present.
A patient with high anxiety asks the nurse to take per pulse and listen to her heart several times an hour.
What is the best way for the nurse to cope with this situation? - Show understanding of the client's
needs by jointly setting up a two hour schedule to monitor her pulse and heart rate.
A 44-year-old male patient has been exposed to a severe amount of radiation after a leak in a reactor
plant. When planning this patient's care, the nurse should implement what action? - The patient should
be carefully protected from infection.
The newly admitted patient has burns on both legs. The burned areas appear white and leather-like. No
blisters or bleeding are present, and the patient states that he has little pain. How should you categorize
this injury? - Full-thickness
What is the rationale for administering tissue plasminogen activator (t-PA) within 3 hours of a
thrombotic stroke? - To cause fibrinolysis of the clot
The male patient with a C-6 spinal cord injury (SCI) tells the home health nurse he has had a severe
pounding headache for the last 2 hours. Which intervention should the home health nurse implement? -
Determine when the patient last urinated.
The nurse is caring for a female patient who sustained a closed head injury 8 days ago due to a motor
vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury? -
The patient tells the nurse she has a stuffy nose and green nasal discharge
A patient is admitted to the hospital with a head injury resulting from an automobile accident. On
admission the patient/clients vital signs are temperature 98.6 F (37 C), blood pressure 128/68, pulse
110, and respirations 26. One hour after admission, the nurse notes the presence of the Cushing's triad
when the patient's vital signs are - Blood pressure 156/60, pulse 60, respirations 14
