D446 Adult Health 2 OA Review

Question

Answer

Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) would be reported to the primary health care provider (PHCP)?

Cloudy yellow dialysate output

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor?

Omitting doses of medication

The nurse is providing teaching to a client with breast cancer who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching?

"I can't believe my hair loss is going to be permanent."

A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How would the nurse interpret this client statement?

A normal response that indicates the presence of phantom limb sensation

The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer would the nurse include?

Personal history of ulcerative colitis or gastrointestinal polyps

The nurse is caring for a client diagnosed with breast cancer receiving combination chemotherapy. Which nursing intervention is the most appropriate?

Avoid giving agents with the same nadirs and toxicities at the same time.

The nurse is preparing to ambulate a client on the third day after cardiac surgery. What would the nurse plan to do to enable the client to best tolerate the ambulation?

Premedicate the client with an analgesic.

A client who suffered a brain attack (stroke) is prepared for discharge from the hospital. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action would the nurse include in the client's plan of care?

Consider the use of active, passive, or active-assisted exercises in the home.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time?

Emphasize progress in a realistic manner.

A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion to treat spinal instability from severe arthritis. The nurse would prepare to transfer the client from the stretcher to the bed by using which best method?

A transfer (slider) board and the assistance of three people

A cervical radiation implant is placed in a client who is undergoing treatment of cervical cancer. The nurse would initiate which activity prescription as the most appropriate for this client?

Bed rest

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse would anticipate that the client has changes in which component of the nervous system?

Neuronal dendrites

The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item would the nurse consider to be most helpful for this client?

Overhead trapeze

A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When would the nurse plan to administer this medication?

On return from dialysis

The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention would the nurse include in the plan of care?

Monitor for neck swelling.

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of pheochromocytoma. The nurse reads the assessment findings and expects to note documentation of which major symptom associated with this condition?

Hypertension

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?

"I need to apply lotion under the brace to prevent skin breakdown."

A 5-year-old child arrives at the emergency department, and the child's parents state that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia

The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important?

Fractures

The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data would the nurse include? Select all that apply.

Thin body build, Smoking history, Postmenopausal age, Chronic corticosteroid use, Family history of osteoporosis

The nurse is caring for a client diagnosed with bacterial meningitis. Which clinical manifestation would the nurse monitor for, indicating increased intracranial pressure?

Altered mental status

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse would perform which action?

Acknowledge the client's anger and continue to encourage participation in care.

The nurse has provided home care instructions to a client after dermabrasion. Which statement by the client indicates a need for further instruction?

"I need to keep my skin dry to allow it to heal."

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse would place the client with an incision in the anterior or middle fossa in which position?

With the head of the bed elevated at least 30 degrees

A client receiving total parenteral nutrition (TPN) has a history of heart failure. The primary health care provider (PHCP) has prescribed furosemide 40 mg by mouth daily to prevent fluid overload. Which laboratory value would the nurse monitor to identify the presence of an adverse effect of this medication?

Potassium

The client has an impairment of cranial nerve II. Specific to this impairment, what would the nurse plan to do to ensure client safety?

Provide a clear path for ambulation without obstacles.

The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about the prevention of pressure injuries while the client has limited mobility. Which statement by the client indicates the need for further teaching?

"I can sit in my favorite chair all day."

The nurse measures the cardiac output of a client and finds it to be 6 L/min. Which amount of kidney perfusion would the nurse anticipate?

1000 to 1200 mL/min

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis (DKA). Which assessment findings are consistent with this diagnosis? Select all that apply.

Polyuria, Polydipsia, Dry mouth, Flushed, dry skin

The nurse is providing instructions regarding the complications of peritoneal dialysis. The nurse emphasizes that onset of peritonitis, a serious complication, is most likely to be associated with which clinical manifestation?

Fever

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions would the nurse plan to promote client safety? Select all that apply.

Provide the client with a soft toothbrush., Instruct the client to use an electric razor., Monitor all secretions for frank or occult blood.

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly?

Hypothalamus

The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What would the nurse assess?

Affect or emotions

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action?

Medicate the client.

The nurse is caring for a client with metastatic breast cancer. The client describes a new and sudden sharp pain in the back. Based on this assessment finding, which is the priority nursing intervention?

Notify the primary health care provider (PHCP).

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?

"I should use polyunsaturated oils in my diet."

The home health nurse is visiting a client with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional?

A neuropsychologist

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels

The nurse has provided dietary instructions to a client with renal calculi who must learn about the foods that yield an alkaline residue in the urine. The nurse determines that education was effective if the client chooses which selections from a diet menu?

Spinach salad, milk, and a banana

The nurse provides discharge instructions to a client after skin patch testing to assess for allergies. Which instruction would be included on the discharge sheet for the client?

Keep the test sites dry.

A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client needs further teaching of the directions if which statement is made?

"I need to scrub the skin vigorously with soap and water."

The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply.

Lying prone, Sitting using a lumbar roll or pillow, Standing with one foot on a step or stool

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

Pedal edema

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse would plan which actions as a priority? Select all that apply.

Place the client on a cardiac monitor., Notify the primary health care provider (PHCP)., Review the client's medications to determine whether any contain or retain potassium.

The nurse is providing home care instructions to the client with a diagnosis of Cushing's syndrome and prepares a list of instructions for the client. Which instructions would be included on the list? Select all that apply.

The signs and symptoms of hypoadrenalism,

Instructions to take the medications exactly as prescribed,

The importance of maintaining regular outpatient follow-up care,

A reminder to read the labels on over-the-counter medications before purchase

The nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's disease. The nurse would check which diagnostic test noted in the client's record to determine the stage of the disease?

Positron emission topography (PET) scan

A client is admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which assessment question would assist in eliciting the most specific data regarding the cause of this syndrome?

"Do you use tampons during your menstrual period?"

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention would the nurse plan to perform?

Perform sterile dressing changes.

The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How would the nurse assess for the presence of Nikolsky's sign?

Note skin blistering and sloughing with finger pressure.

A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH,7.35 (7.35); Paco2​,43 mm Hg (43 mm Hg); Pao2​,58 mm Hg (58 mm Hg); HCO3​,23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter?

Pao2​

Which tests can be used to diagnose gout? Select all that apply.

Serum uric acid level, Synovial fluid aspiration, 24-hour urine uric acid level

A fluorescent antinuclear antibody titer (FANA) is performed in a client suspected of having rheumatoid arthritis (RA). Which laboratory value is most consistent with RA?

1:20

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse anticipate the physician to most likely prescribe? Select all that apply.

Strict bed rest, Elevation of the right leg, Application of moist heat to the right leg, Monitoring for signs of pulmonary embolism

The nurse is reinforcing dietary management to prevent the formation of calcium oxalate renal calculi to a client with a history of recurrent renal calculi. Which client statement would indicate a need for further teaching?

"I will increase the amount of spinach in my diet and be sure to eat nuts as snacks."

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How would the nurse assess for this disease?

Checking for a rash on the digits

A client is about to begin hemodialysis. Which measures would the nurse employ in the care of the client? Select all that apply.

Using sterile technique for needle insertion, Using standard precautions in the care of the client, Wearing full protective clothing such as goggles, mask, gloves, and apron

A nurse is caring for a client with thyrotoxicosis who is at risk for the development of thyroid storm. To detect this complication, the nurse would assess for which sign or symptom?

Persistent sweating

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse would report the cardiac rhythm to be which rhythm?

Normal sinus rhythm

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

The client is aphasic., The client has weakness on the right side of the body., The client has weakness on the right side of the face and tongue., The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

"I don't need to use my walker to get to the bathroom."

The registered nurse (RN) is educating a new nurse on mitral stenosis. Which statement by the new nurse indicates that the teaching has been effective?

"Left atrium to left ventricle narrowing will impede flow of blood."

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client?

The need for sensory stimulation

The nurse is assessing a client who has a diagnosis of goiter. Which would the nurse expect to note during the assessment of the client?

An enlarged thyroid gland

The nurse seeks treatment in an ambulatory clinic for a complaint of hoarseness that has lasted for 6 weeks. On the basis of this symptom, the nurse would consider developing a plan of care for which possible medical diagnosis?

Laryngeal cancer

The nurse is assessing the client's condition after cardioversion. Which observation would be of highest priority to the nurse?

Status of airway

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question?

"Are you getting up at night to urinate?"

The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status?

Level of consciousness

The nurse has taught the client with polycystic kidney disease about management of the disorder and prevention and recognition of complications. The nurse would determine that the client understands the instructions if the client states that which needs to be reported to the primary health care provider (PHCP)? Select all that apply.

Burning on urination, New-onset shortness of breath, A temperature of 100.6∘F (38.1∘C)

The nurse is preparing for a client's postoperative return to the unit after a parathyroidectomy procedure. The nurse would ensure that which piece of medical equipment is at the client's bedside?

Tracheotomy set

A 27-year-old client is undergoing evaluation of lumps in the breasts. In determining whether the client could have fibrocystic breast disorder, the nurse would ask the client whether the breast lumps seem to become more prominent or troublesome at which time?

Before menses

The nurse is preparing to perform a discharge teaching with a client who is started on hemodialysis. Which information would the nurse provide regarding the hemodialysis schedule?

3 to 4 hours of treatment, 3 days per week

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that they have a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention would the nurse anticipate to be prescribed initially for the client?

Regular insulin via the intravenous (IV) route

A client complains of fever, perineal pain, urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?

Tender and edematous prostate gland

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.

Tremors, Irritability, Nervousness

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?

Notify the primary health care provider (PHCP).

The nurse is taking a history from a client suspected of having testicular cancer. Which data will be most helpful in determining the risk factors for this type of cancer?

Age and race

The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Adequacy of capillary filling

The nurse is assessing a client for signs and symptoms of peritonitis. Which of the following signs or symptoms would alert the nurse to the possibility of this condition? Select all that apply.

Nausea, Vomiting, Temperature of 102∘F (38.9∘C)

The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client?

Subnormal temperature and hypotension

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Respiratory distress

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which would the nurse include in the plan of care for the client?

Instruct the client to turn the head to scan the right visual field.

The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how a heart problem can affect the kidneys. The nurse would formulate a response using what fact about the kidneys?

The kidneys generally require and receive about 20% to 25% of the resting cardiac output.

The nurse is providing instructions to the client who is receiving external radiation therapy to the breast for the treatment of cancer. Which statement, if made by the client, indicates the need for further instruction?

"I will use a washcloth to wash the affected area."

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications to take to reduce GERD symptoms. The nurse determines there is a need for further teaching if the client makes which statement?

"Skipping breakfast and lunch and eating a large dinner will decrease my symptoms."

The nurse is preparing a client with suspected nonalcoholic fatty liver disease (NAFLD) for a closed liver biopsy. The client asks the nurse where on the body the needle will be inserted to obtain a tissue specimen. What is the appropriate nursing response?

Between the seventh or eighth and ninth intercostal spaces on the right side of the body

A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications would the nurse inform the client about? Select all that apply.

Infection, Post-treatment blood clots

A hospitalized client is diagnosed with type 1 diabetes mellitus. The nurse plans care for the client, understanding that which factors are likely causes of the beta cell destruction that accompanies this disorder? Select all that apply.

Viruses, Genetic factors, Autoimmune factors, Human leukocyte antigen (HLA)

A client with diabetes mellitus is being tested to determine long-term diabetic control. Which result would the nurse expect to see if the client's long-term control is within acceptable limits?

Glycosylated hemoglobin of <6%

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that they would report which early symptom of compartment syndrome?

Pain that is out of proportion to the severity of the fracture

The nurse is reviewing the pathophysiology of bowel perforation. Which of the following would the nurse identify as a noniatrogenic cause of a bowel perforation?

Ruptured gastric ulcer

A client has urinary calculi composed of uric acid. The nurse is teaching the client dietary measures to prevent further development of uric acid calculi. The nurse would inform the client that it is acceptable to consume which item?

Cottage cheese

The nurse is caring for a client with a serum phosphorus level of 5.0 mg/dL (1.61 mmol/L). What other laboratory value might the nurse expect to note in the medical record?

Calcium level of 8 mg/dL (2.0 mmol/L)

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?

Notify the surgeon.

The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit?

Pulse rate increases from 100 beats/min to 136 beats/min

A client with hypovolemia experiences activation of the renin-angiotensin system to maintain blood pressure. The registered nurse determines that the new nurse understands that what substance is secreted if which statement is made?

"Aldosterone will be secreted."

The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective?

"The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells."

The nurse is caring for a client diagnosed with a ureteral stricture. Which client laboratory value is indicative of worsening ureteral obstruction?

Serum creatinine 1.7 mg/dL (150 mcmol/L)

The nurse notes that the physician has documented that the client has obstructive overflow incontinence. The nurse plans care with the understanding that which is a cause of this type of incontinence?

Uterine prolapse