Question 1

The emergency department nurse is triaging clients.  Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment?

Accepted Answer

A) History of Bell's palsy with unilateral facial droop and drooling 
B) History of multiple sclerosis and reporting recent blurred vision 
C) Reports unilateral facial pain when consuming hot foods 
D) Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

Question 2

The nurse is caring for a client with a history of headaches.  The client has talked to the nurse, smiled at guests, and maintained stable vital signs.  The nurse notes the following changes in the client's status.  Which assessment finding is criticalto report to the health care provider (HCP)?

Accepted Answer

A) Blood pressure 136/88 mm Hg 
B) Flat affect and drowsiness 
C) Poor appetite 
D) Respiratory rate 12/min

Question 3

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

Accepted Answer

A) Apply anti-embolism stockings 
B) Assist with early ambulation 
C) Offer stool softeners 
D) Provide low-fat foods

Question 4

After receiving report, which client should the nurse assess first?

Accepted Answer

A) Client on a heparin infusion with platelet count of 86,000/mm3 (86 x 109/L) 
B) Client with dehydration with blood urea nitrogen of 24 mg/dL (8.57 mmol/L) 
C) Client with myelodysplastic syndrome with white blood cell count of 2,000/mm3 (2.0 x 109/L) 
D) Client with sickle cell disease with hemoglobin of 7.9 g/dL (79 g/L) and hematocrit of 24% (0.2
D)

Question 5

The home care nurse is making an initial visit to a client just discharged after admission for severe exacerbation of chronic obstructive pulmonary disease (COPD).  The nurse observes wall-to-wall stacks of old newspapers and magazines in every room, with pathways that just allow passage from one room to another.  What is the priority nursing action?

Accepted Answer

A) Call the mobile community mental health crisis unit 
B) Contact a service to remove the newspapers and magazines 
C) Reconcile the client's discharge medications 
D) Teach the safe use of oxygen

Question 6

An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation.  Pulse oximetry is 84% on room air.  The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe.  Which prescription should the nurse question?

Accepted Answer

A) Albuterol 2.5 mg by nebulizer 
B) Intravenous (IV) methylprednisolone 125 mg now and every 6 hours 
C) IV morphine 2 mg now and may repeat every 2 hours 
D) Oxygen at 2 L/min by nasal cannula

Question 7

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling.  The health care provider diagnoses a lateral ankle sprain.  Which interventions does the nurse include in the discharge instructions?  Select all that apply.

Accepted Answer

A) Apply heat to reduce swelling during the first 24 hours 
B) Begin an exercise rehabilitation program when the pain subsides 
C) Elevate the leg above the heart level on 2 pillows 
D) Flex and dorsiflex the foot to prevent stiffness during the first 24 hours 
E) Take ibuprofen every 6 hours as needed
F)Wrap the ankle with an elastic compression bandage

Question 8

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss.  The nurse's response is based on an understanding of which of the following?

Accepted Answer

A) Fasting for 7 days is not likely to cause health problems 
B) Fasting spares protein in favor of fat metabolism 
C) Fasting will help control hunger pangs in the long term 
D) Initial weight loss during fasting is primarily from fluid loss

Question 9

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma.  Which clinical finding warrants immediate intervention?

Accepted Answer

A) Hairnet-like effect across vision 
B) Loss of memory about the collision 
C) Temporal headache 
D) Tongue laceration oozing blood

Question 10

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease.  Which statement by the client indicates a need for further teaching?

Accepted Answer

A) "I need to enroll in a smoking cessation program." 
B) "I need to restrict the amount of potassium in my diet." 
C) "I will lie down and avoid walking unassisted during acute attacks." 
D) "I will limit the amount of caffeine and alcohol that I consume."

Question 11

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP).  The nurse will need to notify the HCP about which client?

Accepted Answer

A) A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg 
B) A client just admitted from the emergency department with a BP of 150/72 mm Hg 
C) A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin 
D) A client with heart failure on metoprolol with a BP of 106/42 mm Hg

Question 12

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease.  Which strategies should the nurse include?  Select all that apply.

Accepted Answer

A) Choose foods that are low in fat 
B) Do not consume any foods containing dairy 
C) Eat three large meals a day and minimize snacking 
D) Limit or eliminate the use of alcohol and tobacco 
E) Try to avoid caffeine, chocolate, and peppermint

Question 13

A client with suspected moderate to large pericardial effusion is admitted for monitoring.  The nurse performs a head-to-toe assessment.  Which of these findings indicate likely cardiac tamponade and require immediate intervention?  Select all that apply.

Accepted Answer

A) Blood pressure of 90/70 mm Hg 
B) Bounding peripheral pulses 
C) Decreased breath sounds on left side 
D) Distant heart tones 
E) Jugular venous distension

Question 14

The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur.  Which client information is most important to report to the primary health care provider (PHCP)?

Accepted Answer

A) Blood pressure change from 128/80 mm Hg to 90/50 mm Hg 
B) Development of a 1st-degree atrioventricular (AV) block on electrocardiogram (ECG) 
C) Reports of right femur pain of 7 on a scale of 1-10 
D) Vesicular breath sounds auscultated over the lung tissue

Question 15

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis.  Blood pressure is 80/60 mm Hg.  Which prescribed intervention should the nurse implement first?

Accepted Answer

A) Administer IV antibiotics 
B) Infuse bolus of IV normal saline 
C) Prepare to assist with lumbar puncture 
D) Transport client for head CT scan

Question 16

A client had a percutaneous nephrolithotripsy 3 hours ago to remove left renal calculi.  Since then, the indwelling urethral catheter has drained 125 mL of urine and the nephrostomy tube has drained 0 mL.  The client now reports left flank pain radiating to the left groin along with severe nausea.  What is the appropriate nursing intervention?

Accepted Answer

A) Assess the urethral catheter for kinks and obstruction 
B) Irrigate the nephrostomy tube with sterile normal saline as prescribed 
C) Irrigate the urethral catheter with sterile normal saline as prescribed 
D) Place the client in the prone position to facilitate urine drainage

Question 17

A client on a medical-surgical unit is receiving heparin therapy.  Platelet levels decreased from 230,000/mm3 (230 × 109/L) 2 days ago to 80,000/mm3 (80 × 109/L) today.  Which nursing actions are appropriate?  Select all that apply.

Accepted Answer

A) Confirm validity of platelet result with new blood specimen 
B) Hold the scheduled morning dose of heparin 
C) Notify the health care provider of the platelet count 
D) Obtain a full set of vital signs 
E) Request change of prescription for heparin to enoxaparin

Question 18

A client is admitted to the intensive care unit with suspected pheochromocytoma.  The client's vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min.  The client is sweating profusely and reports a severe headache.  Which prescription should the nurse implement first?

Accepted Answer

A) Draw labs to assess electrolyte panel 
B) Give acetaminophen 650 mg by mouth as needed for headache 
C) Place a fan in the client's room 
D) Start nitroprusside infusion at 0.5 mcg/kg/min

Question 19

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved.  Which of the following instructions should the nurse include to prevent the reoccurrence of DVT?  Select all that apply.

Accepted Answer

A) "Do not take car rides longer than 4 hours for at least 3-4 weeks." 
B) "Drink plenty of fluids every day and limit caffeine and alcohol intake." 
C) "Elevate legs on a footstool when sitting and dorsiflex the feet often." 
D) "Resume your walking program as soon as possible after getting home." 
E) "Sit in a cross-legged position for 5-10 minutes to improve circulation."

Question 20

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal.  The client is concerned about swelling in her arm on the affected side.  Which instructions should the nurse discuss with the client?  Select all that apply.

Accepted Answer

A) Avoid massaging the area 
B) Avoid receiving vaccinations in the affected arm 
C) Elevate the arm above the heart 
D) Perform isometric exercises 
E) Use an intermittent pneumatic compression sleeve

Exam 1: Adult Health

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment?

The nurse is caring for a client with a history of headaches. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is criticalto report to the health care provider (HCP) ?

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

After receiving report, which client should the nurse assess first?

An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe. Which prescription should the nurse question?

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider diagnoses a lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that apply.

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss. The nurse's response is based on an understanding of which of the following?

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma. Which clinical finding warrants immediate intervention?

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP) . The nurse will need to notify the HCP about which client?

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply.

The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur. Which client information is most important to report to the primary health care provider (PHCP) ?

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first?

A client on a medical-surgical unit is receiving heparin therapy. Platelet levels decreased from 230,000/mm³ (230 × 10⁹/L) 2 days ago to 80,000/mm³ (80 × 10⁹/L) today. Which nursing actions are appropriate? Select all that apply.

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply.

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? Select all that apply.