ADULT HEALTH 2 FINAL EXAM
1. Because of normal changes due to aging, the nurse anticipates that a 75-year old client's
serum creatinine level might be what amount?
A) 0.3 mg/dL
B) 2.4 mg/dL
C) 4.8 mg/dL
6.4 mg/dL ANS A) 0.3 mg/dL
Serum creatnine level reflects the by product of muscle breakdown, and an older adult
with less muscle mass can be expected to have a lower than normal level such as 0.3
mg/dL. The normal creatinine range for adults is 0.5-1.5 mg/dL.
A higher than normal level would not be expected for an older patient
2. During an assessment of a client's cranial nerves, the nurse states, "please stick out
your tongue." The nurse observes that the tongue deviates markedly to the right side.
What is the patient's most likely exhibiting?
A) Sluggish oculomotor response.
B) Abnormal hypoglossal nerve response
C) First cranial nerve (CN1) damage
, ADULT HEALTH 2 FINAL EXAM
D) absence of Homans sign ANS B) Abnormal hypoglossal nerve response
Cranial nerve XII(Hypoglossal) is tested by having the patient stick out the tongue. An
abnormal finding is that the tongue deviates to either side. Cranial nerve I is the olfactory
nerve and is assessed by having patient use the sense of smell; cranial nerve III is the
oculomotor nerve and, along with the trochlear and abducens nerves, helps the eye move.
Homans sign is a check for thrombophlebitis int he calves.
3. During the palpation of a client's chest for expansion, the nurse notices a decrease in the
expansion of the right side. This finding is consistent with what health problem? Select All
that apply
A) Emphysema
B) Pneumonia
C) Pleural effusion
D) Heart failure
E) Pneumothorax ANS B) Pneumonia
Thoracic expansion is decreased on the affected side in pneumonia, pneumothorax, and
pleural effusion. Bilateral chest expansions is decreased in emphysema. Heart failure
would not result in a change in chest expansion.
, ADULT HEALTH 2 FINAL EXAM
4. A client with Cushing's Syndrome is concerned about having a head cold every few
weeks. What should the nurse do to address this clients concern?
A) Review coping strategies
B) Encourage daily weights
C) Plan for frequent rest periods
D) Assess for protein and vitamin intake ANS D) Assess for protein and vitamin intake
The patient with Cushing syndrome is at risk for infection due to the overproduction of
glucocorticoids. The nurse should teach the importance of increasing intake of protein and
vitamin C & A, which are all needed to support and repair body tissues. Rest periods and
daily weights are recommended in the care of a patient with Cushing, but neither directly
addresses the problem of frequent infections. There is no indication of a need to review or
change coping strategies.
, ADULT HEALTH 2 FINAL EXAM
5. The nurse is evaluating the effectiveness of dietary teaching provided to a client with
chronic kidney disease. Which menu choices indicate that the client understands the
dietary regimen?
A) Apples and oatmeal for breakfast; peanut butter sandwich for lunch; pasta with fish
for dinner
B) Bacon and eggs for breakfast; hot dog w/ sauerkraut for lunch; baked canned ham
w/ green peas for dinner
C) Two bananas for breakfast; rice and beans for lunch; fruit salad, green beans, and an
8 oz steak for dinner
D) Half a cantaloupe and three eggs for breakfast; a baked potato w/ processed cheese
spread and broccoli for lunch; chicken, pinto beans, squash, and pecan
pie for dinner
ANS A) Apples and oatmeal for breakfast; peanut butter sandwich for lunch; pasta with
fish for dinner
The patient with chronic kidney disease needs to adhere to a low-protein, sodium- and
potassium-restricted diet. Menu choices that include large amounts of protein, potassium,
and sodium in processed foods indicate that dietary teaching was not effective.
1. Because of normal changes due to aging, the nurse anticipates that a 75-year old client's
serum creatinine level might be what amount?
A) 0.3 mg/dL
B) 2.4 mg/dL
C) 4.8 mg/dL
6.4 mg/dL ANS A) 0.3 mg/dL
Serum creatnine level reflects the by product of muscle breakdown, and an older adult
with less muscle mass can be expected to have a lower than normal level such as 0.3
mg/dL. The normal creatinine range for adults is 0.5-1.5 mg/dL.
A higher than normal level would not be expected for an older patient
2. During an assessment of a client's cranial nerves, the nurse states, "please stick out
your tongue." The nurse observes that the tongue deviates markedly to the right side.
What is the patient's most likely exhibiting?
A) Sluggish oculomotor response.
B) Abnormal hypoglossal nerve response
C) First cranial nerve (CN1) damage
, ADULT HEALTH 2 FINAL EXAM
D) absence of Homans sign ANS B) Abnormal hypoglossal nerve response
Cranial nerve XII(Hypoglossal) is tested by having the patient stick out the tongue. An
abnormal finding is that the tongue deviates to either side. Cranial nerve I is the olfactory
nerve and is assessed by having patient use the sense of smell; cranial nerve III is the
oculomotor nerve and, along with the trochlear and abducens nerves, helps the eye move.
Homans sign is a check for thrombophlebitis int he calves.
3. During the palpation of a client's chest for expansion, the nurse notices a decrease in the
expansion of the right side. This finding is consistent with what health problem? Select All
that apply
A) Emphysema
B) Pneumonia
C) Pleural effusion
D) Heart failure
E) Pneumothorax ANS B) Pneumonia
Thoracic expansion is decreased on the affected side in pneumonia, pneumothorax, and
pleural effusion. Bilateral chest expansions is decreased in emphysema. Heart failure
would not result in a change in chest expansion.
, ADULT HEALTH 2 FINAL EXAM
4. A client with Cushing's Syndrome is concerned about having a head cold every few
weeks. What should the nurse do to address this clients concern?
A) Review coping strategies
B) Encourage daily weights
C) Plan for frequent rest periods
D) Assess for protein and vitamin intake ANS D) Assess for protein and vitamin intake
The patient with Cushing syndrome is at risk for infection due to the overproduction of
glucocorticoids. The nurse should teach the importance of increasing intake of protein and
vitamin C & A, which are all needed to support and repair body tissues. Rest periods and
daily weights are recommended in the care of a patient with Cushing, but neither directly
addresses the problem of frequent infections. There is no indication of a need to review or
change coping strategies.
, ADULT HEALTH 2 FINAL EXAM
5. The nurse is evaluating the effectiveness of dietary teaching provided to a client with
chronic kidney disease. Which menu choices indicate that the client understands the
dietary regimen?
A) Apples and oatmeal for breakfast; peanut butter sandwich for lunch; pasta with fish
for dinner
B) Bacon and eggs for breakfast; hot dog w/ sauerkraut for lunch; baked canned ham
w/ green peas for dinner
C) Two bananas for breakfast; rice and beans for lunch; fruit salad, green beans, and an
8 oz steak for dinner
D) Half a cantaloupe and three eggs for breakfast; a baked potato w/ processed cheese
spread and broccoli for lunch; chicken, pinto beans, squash, and pecan
pie for dinner
ANS A) Apples and oatmeal for breakfast; peanut butter sandwich for lunch; pasta with
fish for dinner
The patient with chronic kidney disease needs to adhere to a low-protein, sodium- and
potassium-restricted diet. Menu choices that include large amounts of protein, potassium,
and sodium in processed foods indicate that dietary teaching was not effective.
