Chapter 14

Adult Health Questions

26. The nurse is monitoring a client who had a pleural biopsy. The nurse determines that the client is experiencing a complication if the client exhibits which manifestation?

1. Diaphoresis

2. Warm, dry skin

3. Mild pain at the biopsy site

4. Capillary refill of 2 seconds

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Adult Health

ANSWER: 1

References

deWit, Kumagai (2013), pp. 268, 270; Ignatavicius, Workman (2013), pp. 560-561.

27. The nurse caring for a client following a bowel resection notes that the client is restless. The nurse takes the client’s vital signs and notes that the client’s pulse rate has increased and that the blood pressure has dropped significantly since the previous readings. The nurse suspects that the client is going into shock and should take which immediate action?

1. Check the client’s oxygen saturation level.

2. Recheck the vital signs to verify the findings.

3. Raise the client’s legs above the level of the heart.

4. Slow the rate of the intravenous (IV) fluid infusing.

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Adult Health

ANSWER: 3

Rationale:

In addition to hypotension, manifestations of shock include tachycardia; restlessness and apprehension; and cold, moist, pale, or cyanotic skin. If a client develops signs of shock the nurse should immediately raise the client’s legs above the level of the heart to improve venous return and immediately notify the surgeon. The nurse should also check the client’s pulse oximetry reading, plan to administer oxygen, increase the rate of IV fluids (unless contraindicated), administer medications as prescribed, and continue to monitor the client and the client’s response to interventions.

Test-Taking Strategy:

Note the strategic word immediate. Use the ABCsâ€”airway, breathing, and circulationâ€”to answer the question. This will direct you to the correct option. Raising the client’s legs above the level of the heart will assist in providing blood flow to body tissues. Review: interventions for shock.

Tip for the Beginning Nursing Student:

Shock is an abnormal condition of inadequate blood flow to the body’s tissues resulting in an inadequate delivery of oxygen and nutrients to the tissues. There are different types of shock, but the most common is hypovolemic shock. It is caused by any condition that results in hypovolemia, such as hemorrhage. Fluid volume must be restored immediately to oxygenate perfusion-deprived tissues. This condition can be life threatening if not immediately treated. You will learn about shock as a postoperative complication in your fundamentals of nursing course and in your medical-surgical nursing course.

References

deWit, Kumagai (2013), p. 1040; Ignatavicius, Workman (2013), p. 818.

28. The nurse is performing an assessment on a client with a diagnosis of a brain tumor that is located in the brainstem and notes that the client is assuming the posture in the below figure. The nurse contacts the health care provider and reports that the client is exhibiting which assessment finding? Refer to figure.

(Figure from Ignatavicius D, Workman ML: Medical surgical nursing: Patient-centered collaborative care, ed 7, Philadelphia, 2013, Saunders.)

1. Opisthotonos

2. Flaccid quadriplegia

3. Decorticate posturing

4. Decerebrate posturing

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Adult Health

ANSWER: 4

Rationale:

In decerebrate posturing the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is hyperextended. Decerebrate posturing indicates a lesion in the brainstem at the midbrain or upper pons. Opisthotonos is a prolonged arching of the back with the head and heels bent backward. It indicates meningeal irritation. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem. In decorticate posturing the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate posturing indicates a hemispheric lesion of the cerebral cortex.

Test-Taking Strategy:

Focus on the subject, assessment findings in the client with a brain tumor. Note the position of the client and that the extremities are stiffly extended. Also, noting the client’s diagnosis and recalling that this posture indicates a lesion in the brainstem at the midbrain or upper pons will assist in answering the question. Review: decerebrate posturing.

Tip for the Beginning Nursing Student:

A brain tumor refers to a lesion in the brain. The clinical manifestations that the client exhibits depend on the location of the tumor. If a client has a tumor in the brain, one concern is increased intracranial pressure occurring because of the tumor. Another concern is deterioration in the client’s condition as a result of the tumor pressing on structures in the brain. The nurse needs to monitor the neurological status of the client closely. If the nurse notes posturing, this indicates deterioration in the client’s condition and needs to be reported immediately. You will learn about brain tumors, the signs of increased intracranial pressure, and posturing in your medical-surgical nursing course when you study neurological disorders.

References

deWit, Kumagai (2013), p. 487; Ignatavicius, Workman (2013), pp. 918, 1026.

29. A client newly diagnosed with type 1 diabetes mellitus is taking Humulin N insulin at 0700 daily. The nurse should monitor the client closely for which signs and symptoms in the late afternoon?

1. Increased appetite and abdominal pain

2. Hunger, shakiness, and cool, clammy skin

3. Thirst, red dry skin, and fruity breath odor

4. Increased urination and rapid deep breathing

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Adult Health

ANSWER: 2

Rationale:

The client taking Humulin N insulin would experience peak effects of the medication from approximately 6 to 12 hours after administration. At this time, the client is at risk for hypoglycemia if food intake is insufficient. The nurse should teach the client to watch for signs and symptoms of hypoglycemia, which include hunger, shakiness, cold sweating, headache, anxiety, increased pulse, blurred vision, confusion, and difficulty concentrating, during this time frame. The other options list various manifestations of hyperglycemia.

Test-Taking Strategy:

Focus on the subject, that the client is taking Humulin N insulin at 0700. Also note the words signs and symptoms in the late afternoon. Recall that hypoglycemic reactions can occur at peak insulin times. Recall that Humulin N is an intermediate-acting insulin and peaks during the afternoon. Therefore, you are looking for the option that identifies signs and symptoms of a hypoglycemic reaction. Also, eliminate options 1, 3, and 4 because they are comparable or alike and identify signs and symptoms of hyperglycemia. Remember the 3 Ps of hyperglycemiaâ€”polyuria, polydipsia, and polyphagia. Review: the signs and symptoms of hypoglycemia.

Tip for the Beginning Nursing Student:

Both injectable and oral insulins are used to treat the client with diabetes mellitus, and these medications can cause hypoglycemia. Two important complications of diabetes mellitus are hypoglycemia and hyperglycemia. It is important to know the signs and symptoms of each and the interventions needed if either occurs and to teach this information to the client. You will learn about these complications and the other complications of diabetes mellitus when you study endocrine disorders in your medical-surgical nursing course.

References

deWit, Kumagai (2013), p. 874; Lewis et al (2011), p. 1242.

30. The nurse is developing a teaching plan for the client with viral hepatitis. The nurse should list which item in the plan?

1. Consume three large meals daily.

2. The diet should be low in calories.

3. Activity should be limited to prevent fatigue.

4. Alcohol intake should be limited to 2 oz per day.

Level of Cognitive Ability:

Applying

Client Needs:

Physiological Integrity

Integrated Process:

Teaching and Learning

Content Area:

Adult Health

ANSWER: 3

Rationale:

The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The client should take in several small meals per day rather than three large meals. The diet should be optimal in calories, protein, and carbohydrates. Alcohol is restricted, not limited.

Test-Taking Strategy:

Note the subject, care of the client with viral hepatitis. Eliminate option 4 first using general principles related to client teaching. Next focus on the client’s diagnosis, and recall that the liver needs rest during the healing process. This will direct you to the correct option. Review: care of the client with hepatitis.

Tip for the Beginning Nursing Student:

Viral hepatitis is a viral inflammatory disease of the liver caused by one of the hepatitis viruses. It can be transmitted orally, sexually, through contaminated water or food, or through exposure to infected blood; the mode of transmission varies depending on the type of hepatitis virus. You will learn about viral hepatitis when you study gastrointestinal disorders in your medical-surgical nursing course.

References

deWit, Kumagai (2013), p. 699; Lewis et al (2011), pp. 1062, 1066; Linton, Maebius (2012), pp. 846-848.

31. The nurse is reading the results of the client’s Mantoux tuberculin skin test and palpates a 4-mm area of induration at the test site. The nurse should document which result?

1. Confirms tuberculosis

2. Is positive for tuberculosis

3. Is negative for tuberculosis

4. Provides a conclusive determination of tuberculosis

Level of Cognitive Ability:

Analyzing

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Communication and Documentation

Content Area:

Adult Health

ANSWER: 3

Rationale:

More than 10 mm of induration indicates exposure to and infection with tuberculosis. However, the infection may not be an active one, and the result could indicate the presence of inactive (dormant) disease. More than 5 mm of induration is considered a positive result for clients with known or suspected human immunodeficiency infection, intravenous drug users, people in close contact with a known case of tuberculosis, or clients with a chest radiograph suggestive of previous tuberculosis.

Test-Taking Strategy:

Eliminate options 1, 2, and 4 because they are comparable or alike and indicate that tuberculosis is present. Review: the Mantoux tuberculin skin test.

Tip for the Beginning Nursing Student:

Tuberculosis is an infection caused by an acid-fast bacillus known as Mycobacterium tuberculosis. It is usually transmitted by the inhalation or ingestion of infected droplets and usually affects the lungs. The Mantoux tuberculin skin test is a test that consists of an intradermal injection of a purified protein derivative of the tubercle bacillus. This test is used to assist in establishing a diagnosis of tuberculosis. You will learn about this test and tuberculosis when you study respiratory disorders in your medical-surgical nursing course.

References

deWit, Kumagai (2013), p. 299; Ignatavicius, Workman (2013), p. 655.

32. The nurse is conducting a training session on cardiopulmonary resuscitation (CPR). The nurse should incorporate which guideline in the session?

1. Stop CPR once fatigue is felt.

2. Look, listen, and feel for breathing.

3. Assess circulation first, then airway and breathing.

4. Determine cardiac arrest based on unresponsiveness only.

Level of Cognitive Ability:

Applying

Client Needs:

Physiological Integrity

Integrated Process:

Teaching and Learning

Content Area:

Adult Health

ANSWER: 3

Rationale:

The American Heart Association sets forth guidelines for effective CPR. The current sequence for CPR is compressions, then airway and breathing (CAB). The health care provider should continue CPR until the return of spontaneous circulation or resuscitative efforts are terminated; not once fatigue is felt. Ideally, additional personnel should be available to assist in resuscitative efforts. â€œLook, listen, and feelâ€ is no longer part of CPR procedures. Cardiac arrest is determined based on unresponsiveness and absence of a heart beat and breathing.

Test-Taking Strategy:

Note the subject, guidelines of CPR. Begin by eliminating option 4, noting the closed-ended word only. From the remaining options, recall that the current guidelines implement CAB. Review: cardiopulmonary resuscitation guidelines.

Tip for the Beginning Nursing Student:

Review the guidelines for performing CPR to ensure that you are ready to perform the procedure if an emergency situation arises. Remember that CABâ€”compressions, airway, breathingâ€”is the sequence to follow and that if the client is a victim of injury, such as from a motor vehicle crash or a fall from a ladder, and you suspect a neck injury, the jaw thrust maneuver is used to open the airway. As a health care provider, you will be required to remain current with your CPR certification. You will also review the CPR guidelines in your medical-surgical nursing course when you study cardiac disorders.

References

deWit, Kumagai (2013), pp. 81-82; Ignatavicius, Workman (2013), p. 736.

33. The client has been diagnosed with polycystic kidney disease. The nurse should assess the client for which manifestation that is most common for this disorder?

1. Headache

2. Hypotension

3. Flank pain and hematuria

4. Complaints of low pelvic pain

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Adult Health

ANSWER: 3

Rationale:

The most common findings with polycystic kidney disease are hematuria and flank or lumbar pain that is either colicky in nature or dull and aching. Other common findings include proteinuria, calculi, uremia, and palpable kidney masses. Hypertension is another common finding and may be associated with cardiomegaly and heart failure. The client may complain of a headache, but this is not a specific assessment finding in polycystic kidney disease.

Test-Taking Strategy:

Note the strategic word most. Note the relationship between the word kidney in the name of the disorder and the word flank in the correct option. Review: the manifestations of polycystic kidney disease.

Tip for the Beginning Nursing Student:

Polycystic kidney disease is an abnormal condition in which the kidneys are enlarged and contain many cysts. The three forms of the disease are childhood polycystic disease, congenital polycystic disease, and adult polycystic disease. Kidney failure can result that can progress to uremia and death. Treatment is symptomatic or may include dialysis or renal transplant. You will learn about this disease in your pediatrics nursing course or your medical-surgical nursing course when you study renal disorders.

References

Christensen, Kockrow: Adult Health (2011), pp. 460-461; Lewis et al (2011), pp. 1142-1143.

34. A client is tested for human immunodeficiency virus (HIV) with an enzyme-linked immunosorbent assay (ELISA) test, and the test result is positive. The client is very upset and asks the nurse if this means that he definitely has HIV. How should the nurse respond to the client?

1. “Yes, you definitely have HIV.”

2. â€œAnother test will be done to determine if you have HIV.â€

3. â€œFalse-positive results are reported all of the time and you should not be worried.â€

4. â€œA positive test means that the infection was diagnosed early in the initial infection period.â€

Level of Cognitive Ability:

Applying

Client Needs:

Physiological Integrity

Integrated Process:

Communication and Documentation

Content Area:

Adult Health

ANSWER: 2

Rationale:

The normal value for an ELISA test is negative. If the ELISA is positive, a second test, the Western blot, is performed to confirm a positive HIV status. The other options are incorrect. In addition, the nurse should not tell a client that â€œhe should not be worried.â€ If testing is performed too early in the initial infection period, a false-negative result may occur.

Test-Taking Strategy:

Use therapeutic communication techniques to eliminate options 1 and 3. Next, careful reading of option 4 will assist in eliminating this option. Remember that if testing is performed too early in the initial infection period, a false-negative result may occur. Review: interpretations of results of an enzyme-linked immunosorbent assay (ELISA) test.

Tip for the Beginning Nursing Student:

HIV is a retrovirus that causes acquired immunodeficiency syndrome (AIDS). The HIV virus is transmitted through anal or oral sexual contact with infected semen or vaginal secretions, through contact with infected blood or blood products, by transmission of the virus from mother to fetus during childbirth, through breastfeeding, or through other infected body fluids. Various blood tests done to confirm the diagnosis include the ELISA and the Western blot. You will learn about these blood tests and HIV when you study immune disorders in your medical-surgical nursing course.

References

deWit, Kumagai (2013), p. 219; Lewis et al (2011), p. 246.

35. The nurse monitors for which acid-base disorder that can likely occur in a client with an ileostomy?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory acidosis

4. Respiratory alkalosis

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Adult Health

ANSWER: 1

Rationale:

Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for developing the acid-base disorders identified in the other options.

Test-Taking Strategy:

Focus on the subject, acid-base disorders. Note that the client has an ileostomy. Because the client does not have a respiratory condition, eliminate options 3 and 4. Next recall that intestinal fluids are alkaline; therefore, alkaline secretions are lost in a client with an ileostomy, resulting in an acidotic condition. Review: causes of metabolic acidosis.

Tip for the Beginning Nursing Student:

An ileostomy is a surgical formation of an opening of the ileum onto the surface of the abdomen, through which fecal matter is emptied. This surgical procedure is performed for conditions such as advanced or recurrent ulcerative colitis, Crohn’s disease, or cancer of the large bowel. You will learn about an ileostomy when you study gastrointestinal disorders in your medical-surgical nursing course.

References

deWit, Kumagai (2013), p. 48; Ignatavicius, Workman (2013), pp. 202-203.

36. The nurse provides instructions to a client who is being discharged after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions?

1. â€œA fever is normal following this procedure.â€

2. â€œI should not work out at the gym for about 2 weeks.â€

3. â€œI need to avoid any strenuous lifting for about 2 weeks.â€

4. â€œI will call the health care provider if my urine becomes bloody.â€

Level of Cognitive Ability:

Evaluating

Client Needs:

Physiological Integrity

Integrated Process:

Teaching and Learning

Content Area:

Adult Health

ANSWER: 1

Rationale:

Following percutaneous renal biopsy, the client is instructed to report immediately fever, increasing pain levels (back, flank, or shoulder), bleeding from the puncture site, weakness, dizziness, grossly bloody urine, or dysuria. Activity should be restricted if blood is seen in the urine. The client is also instructed to avoid strenuous lifting, physical exertion, or trauma to the biopsy site for up to 2 weeks after discharge.

Test-Taking Strategy:

Note the strategic words need to reinforce the instructions. These words indicate a negative event query and the need to select the option that identifies an incorrect client statement. Eliminate options 2 and 3 first because they are comparable or alike. From the remaining options, recall the complications of this procedure. This will direct you to the correct option. Review: client instructions following a percutaneous renal biopsy.

Tip for the Beginning Nursing Student:

A percutaneous renal biopsy is performed by the insertion of a needle through the skin into the kidney to obtain a piece of tissue for pathological analysis. Infection and bleeding are concerns following this procedure, and the nurse monitors the client closely for these complications. You will learn about a percutaneous renal biopsy when you study renal disorders in your medical-surgical nursing course.

References

deWit, Kumagai (2013), p. 768; Ignatavicius, Workman (2013), pp. 1486-1487; Lewis et al (2011), p. 1118.

37. A client being treated for respiratory failure has the following arterial blood gas (ABG) results: pH 7.30, PaCO₂ 58 mm Hg, PaO₂ 75 mm Hg, 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

1. Metabolic acidosis

2. Metabolic alkalosis

3. Respiratory acidosis

4. Respiratory alkalosis

Level of Cognitive Ability:

Analyzing

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Adult Health

ANSWER: 3

Rationale:

Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PaCO₂. In respiratory acidosis, the pH is decreased and the PaCO₂ is elevated. The normal is 22 to 27 mm Hg. Metabolic acidosis is present when the is less than 22 mEq/L and the pH is less than 7.35, whereas metabolic alkalosis is present when the is greater than 27 mEq/L and the pH is greater than 7.45. This client’s ABG results are consistent with respiratory acidosis.

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Tags: Saunders 2014-2015 Strategies for Test Success Passing Nursing S

Jul 24, 2016 | Posted by admin in NURSING | Comments Off

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