NURSING CARE OF THE ADULT CLIENT

  1. Which of the following observations would be expected in a patient with hyperthyroidism? a) Tremulousness, diaphoresis, and rapid pulse. b) Dyspnea, yellow sclerae, and brittle hair c) Dependent edema, purpura, and drowsiness d) Slow respiration, flattened affect and cool, dry skin 2. Which assessment is essential for the nurse to make in preparing a pt for an intravenous pyelogram? a) Determine if the patient has an allergy to iodine. b) Check date of the patients last bowel movement c) Obtain the patient baseline body temperature orally d) Ascertain when the patient last had an x-ray 3. A patient newly diagnosed with Parkinson disease is being discharged to home. The nurse provides instructions about home care. Which statements best indicate that a) I will avoid siting outside in the sunlight b) My husband will need to take my place on the committee at church c) I will remove the loose scatter rugs from the hallway d) My husband will need to do the household chores from now on 4. The nurse observes that the weights on a patient buck extension are almost touching the floor. Which action should the nurse take? a) Remove some of the weights from the traction b) Elevate the affected leg on a pillow c) Shorten the rope supporting the weights d) Assist the patient up to the head of the bed. 5. A patient with heart failure who is taking digoxin has a low potassium level 24 hours after admission. Which statement is most accurate regarding the implication of a) The low potassium level will be corrected by the medication already prescribed b) The low potassium level is insignificant if the sodium level is normal c) The low potassium level will potentiate digoxin toxicity d) The low potassium level is desirable early in the treatment plan. 6. Which lab value is most likely to be elevated in a patient with cirrhosis a) Total protein b) Alkaline phosphatase c) Creatine phosphokinase d) Hemoglobin 7. The nurse is providing discharge instruction to a patient who had a repair of an abdominal aortic aneurysm. Which instruction is most important to include for the a) Monitoring radial pulse twice a day b) Performing deep breathing and coughing exercises c) Massaging the incisional site with lanolin lotion d) Assessing changes in the appearance of the legs 8. Which action should be taken by the nurse providing perineal care to a patient following surgery to repair a cystocele? a) Manipulating the position of the urinary catheter b) Palpating the abdomen for tenderness c) Having patient contract the perineal muscles several times d) Checking the perineal area for evidence of drainage 9. A patient asks the nurse, what causes pancreatitis? Which response by the nurse is most accurate? a) It is caused by a bacterial infection b) It is a result of a food allergy c) It is an autoimmune disease d) It is due to autodigestion by enzymes 10. A patient is prescribed pilocarpine. Which statement best describes the desired effect of the medication for the patient? a) Stimulates the production of vitreous humor in the eyes b) Inhibits the flow of aqueous humor through the pupils of the eyes c) Reduces the pressure within the eyes d) Reduces the inflammatory process in the eyes 11. A patient with previously untreated tuberculosis is being started on a multi-drug therapy. The patient asks the nurse why do I have to take so many drugs a) Combination therapy is used to reduce the incidence of a synergistic effect from the drugs b) Combination therapy is used to counteract the side effect of each drug c) Combination therapy is used to allow for reduction in the dosage of each drug d) Combination therapy is used to control the emergence of drug-resistance strains 12. Which diagnostic blood test result should the nurse expect to find in a patient with pancreatitis? a) Elevated hemoglobin b) Decreased platelets c) Elevated amylase d) Decreased glucose 13. Which nursing diagnosis would take priority in a care plan for a patient with myasthenia gravis? a) Alteration in comfort b) Altered thought processes c) Activity intolerance d) Urge incontinence 14. Which activity would most likely facilitate a patient recovery during the rehabilitation phase following surgery for breast cancer? a) Having a female member of a mastectomy support group visit before discharge b) Counselling sessions with a psychotherapist for the next three months c) Scheduling an appointment with a breast surgeon for reconstruction d) Encouraging the patient to consider a community agency for home care. 15. A patient is receiving a corticosteroid following surgery for a seizure disorder. What is the expected effect of the corticosteroid for the patient? a) Improvement in the production of cerebrospinal fluid b) Enhancement of neurotransmitters c) Reduction in cerebral edema d) Minimizing brain irritation. 16. During an 8 hour period. 30ml of normal saline solution were installed twice to irrigate the patient’s nasogastric tube. At the end this same 8 hour period. 300ml were emptied from the nasogastric drainage container ---- ml of gastric secretion should be recorded. 17. Postoperative teaching for a patient following surgery for otosclerosis should include which instruction? a) Breathe through the mouth rather than the nose b) Refrain from bending over c) Avoid drinking extremely hot or cold fluids d) Try to yawn at least once per hour 18. Which finding would the nurse expect to find in a patient with hypertension a) A pulse rate above 80 that is weak and thread b) A systolic pressure fluctuating between 120 and 130 mm hg c) A diastolic pressure greater than 90 mm hg d) A pulse pressure less than 40 mm hg 19. A patient’s pulmonary function test results indicate a diminished vital capacity and an increased residual volume. Based on these results, which nursing diagnosis a) Decreased cardiac deficit b) Fluid volume deficit c) Activity intolerance d) Ineffective thermoregulation 20. Strong iodine (lugol’s) solution is prescribed for a patient with hyperthyroidism. On a two-week follow up, the nurse should expect to to obtain which data about a) The pulse rate is rapid b) The hair is coarse and dry c) The serum thyroxin level is within normal limits d) The thyroid is not palpable 21. A patient asks the nurse what is Parkinson disease? The nurse response should be based on which statement? a) It is a result of demyelination of the neurons b) It is due to defect in the basal ganglia c) It is related to a genetic malfunction d) It is caused by a hormonal imbalance 22. A patient receiving furosemide is given instruction to increase the dietary intake of potassium. Which choice indicates patient understanding of foods high in potassium a) Dried apricots b) Corn bread c) Cranberry sauce d) Cooked oatmeal 23. A patient is recovering following surgery for rectal cancer. Which nursing diagnosis should be given priority in the care plan during the postoperative period a) Self care deficit b) Body image disturbance c) Anticipatory grieving d) Alteration in nutrition 24. A patient with uncontrolled diabetes has a glucose level of 430 mg/dl. Which inulin preparation should the nurse anticipate giving intravenously? a) Insulin injection (regular) b) Protamine zinc (PZI) c) Zinc suspension (lente) d) Isophane (NPH) 25. A patient recovering from hip surgery is given instruction about hip movement. Which statement by the patient indicates understanding of the instructions? a) I will put my extremity through its full range of motion b) I will use an assistive device when walking c) I will bend forward when lying my shoes d) I will stoop to pick up objects from the floor 26. A patient with hypertension reports eating most meals in restaurants. Which food should the nurse instruct the patient to avoid? a) Broiled fish b) Baked chicken c) Roast beef d) Smoked ham 27. Which side effect should the nurse monitor in a patient who is prescribed propranolol hydrochloride? a) Blurred vision b) Tinnitus c) Dry mouth d) Bradycardia 28. A nurse gives a patient instruction in preparation for a laryngoscopy. Which statement by the patient indicates understanding of the instructions? a) I will gag throughout the procedure b) I will drink a while chalky liquid before the procedure c) I will have my throat anesthetized just prior to the procedure d) I will be asleep during the procedure 29. Which symptom would the nurse expect a patient with cataracts to report? a) Increased intraocular pressure b) Blurred vision c) Bilateral eye pain d) Narrowed visual fluid 30. A patient with symptoms of myocardial infarction is to receive morphine sulfate 8mg intravenously every 4 hours as needed. Two hours after receiving a) Administer half of the prescribed dose of morphine to the patient b) Consult with the health care provider about the patient’s report of pain c) Reposition the patient and reassess pain in an hour d) Assure patient that he can receive morphine again in two hours. 31. Which nursing measure is most appropriate to take while a patient is undergoing a lumbar puncture? a) Instructing the patient to hold his/her breath periodically during the procedure