Exam 1: Adult Health

The client with suspected active pulmonary tuberculosis (TB) has a positive tuberculin skin test (TST).  Which prescription from the health care provider does the nurse anticipate will confirm the diagnosis in this client?

A client at 32 weeks gestation has been diagnosed with syphilis.  The client expresses to the nurse her belief that antibiotic therapy is harmful and refuses treatment.  What is the nurse's appropriate response at this time?

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves.  The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding?

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV).  Which action by the new RN indicates the need for further education?

The nurse is participating in a staff presentation to review risk factors for skin cancer.  Which of the following risk factors should the nurse include?  Select all that apply.

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation.  Which statement would be a priority for the nurse to report to the health care provider?

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease.  Which nursing action(s) should be included in the client's plan of care?  Select all that apply.

A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat.  The client has a pulse of 135/min, respirations 32/min, and oxygen saturation 84%.  The client also has circumoral cyanosis and decreased level of consciousness.  Place the nurse's actions while awaiting the arrival of the rapid response team in priority order.  All options must be used.

A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy.  The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit.  Which statement by the unlicensed assistive personnel would require immediate action by the nurse?

An adult client with bacterial pneumonia becomes increasingly disoriented and somnolent.  Which assessment findings indicate that the client may be in septic shock?  Select all that apply.

The nurse assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration.  The client has no symptoms.  Which action will the nurse take next?

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner.  Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week.  Which action is appropriate for the nurse to recommend to the client?

The nurse assesses these symptoms in a client with bacterial pneumonia: chills, elevated temperature, tachypnea, productive cough of yellow sputum, shortness of breath, and fatigue.  Based on the assessment data, what is the most appropriate nursing diagnosis (ND) for this client?

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis?

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke.  Which of the following deficits would the nurse correctly attribute to Broca aphasia?  Select all that apply.

A client is seen following a motor vehicle collision.  An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital.  The IV line is now infusing at 200 mL/hr.  Which assessment finding alerts the nurse to the development of hypovolemic shock?

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease.  What instructions should the nurse include?  Select all that apply.

The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow.  Which statement made by the client indicates an understanding of the nurse's teaching?

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound.  Which of the following values would be a priority for the nurse?

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L).  What is the priority prescribed intervention?