Adult Health Assessment
The nurse is assessing a healthy middle-aged adult. Which finding should the nurse expect?
1. Weight gain of 20 pounds in the past year
2. Tactile fremitus is absent at the apex of the lungs
3. Counts backward from 100 subtracting 7 each time
4. Percussion shows heart is larger than at last checkup
3. The nurse should expect that the middle-aged adult should be able to focus on a mental task such as subtraction.
The client is taking gabapentin. The nurse evaluates that gabapentin is effective when obtaining which assessment findings?
1. Less muscle weakness and decreased spasticity
2. Decrease in chronic pain intensity and seizures
3. Increased WBC count and increased hemoglobin
4. Improvement in mobility and cognitive function
2. Gabapentin (Neurontin) is an adjunct antiepileptic medication used in treating partial or mixed seizures. It also has unlabeled uses in preventing headaches and controlling chronic pain.
When the office nurse completes height measurement for the 72-year-old female, the client says that she lost half an inch. Which explanation by the nurse is most accurate?
1. “As we age, we lose muscle mass.”
2. “Bone loss is due to lack of exercise.”
3. “As we age, we lose knee and hip cartilage.”
4. “The vertebral column shortens with aging.”
4. With aging, there is shortening and thinning of the vertebral column due to loss of water and bone density, causing compression resulting in decreased height.
The experienced nurse is observing the new nurse recommend screening tests to the 80-year-old female client. Which recommendation made by the new nurse should the experienced nurse correct?
1. Hearing screen annually
2. Colonoscopy every 10 years
3. Pneumococcal vaccine annually
4. Mammogram every 1 to 2 years
3. Pneumococcal vaccine is administered at age 65 and every 10 years, not annually. An influenza vaccine should be administered annually.
The client receiving hospice care has oxygen at 4L/NC. Which interventions should the nurse implement when the client develops increased respiratory effort, copious secretions, and increasing respiratory distress? Select all that apply.
1. Increase the dosage of morphine sulfate.
2. Raise the head of the bed to 60 degrees.
3. Administer hyoscyamine as prescribed.
4. Administer an expectorant medication.
5. Obtain a fan to circulate air in the room.
1. Dyspnea in hospice clients is treated with morphine sulfate to decrease venous return and to ease the effort of breathing.
2. Raising the head of the bed improves lung expansion.
3. Hyoscyamine (Levsin) is an anticholinergic medication that dries respiratory secretions.
5. Circulating air from the fan often reduces the effort the client must put into breathing.
The nurse is assessing the 50-year-old female client who is hospitalized. The nurse should assess the client for which physical change associated with aging?
1. Increased sweat gland activity
2. Decreased ability to read smaller print
3. Weight loss due to hypermetabolism
4. Increased sebaceous gland activity
2. Visual acuity declines in middle-aged adults, often by the late 40s, especially near vision.
The nurse is to administer 40 mg of furosemide to the client. The prefilled syringe reads 100 mg/mL. How many milliliters should the nurse administer to the client?
__________ mL. (Record your answer rounded to the nearest tenth.)
The nurse should administer 0.4 mL of furosemide (Lasix).
The nurse completes teaching for the 80-year-old female client. Which statement made by the client indicates further teaching is needed?
1. “Instead of using sodium seasonings, I plan to try one with herbs and lemon.”
2. “Although I find my lavender-scented hand cream relaxing, I should not use it.”
3. “I should place a towel on the floor outside my shower so I don’t slip when getting out.”
4. “Rather than relying on laxatives, I should increase my intake of fruits and vegetables.”
3. Placing a towel outside the shower on the floor can increase the client’s risk for a fall. A slip-resistant mat should be used and the towel placed within reach without bending.
The nurse is reviewing a laboratory report for a 61-year-old client. Which finding is most important for the nurse to address with the HCP?
1. Total cholesterol 180 mg/dL; was 140 at age 50
2. Erythrocyte sedimentation rate (ESR) increased
3. Alkaline phosphatase increased
4. AST, ALT, and serum bilirubin increased
4. It is most important for the nurse to notify the HCP if liver function tests are elevated. AST, ALT, and serum bilirubin are liver function tests that are unchanged with age.
The older adult client is admitted to the ED after a fall. Which medications, if taken by the client, should the nurse identify as psychotropic drugs that may have contributed to the fall? Select all that apply.
1. Alprazolam 1 mg daily
2. Docusate sodium 100 mg daily
3. Hydrochlorothiazide 25 mg daily
4. Potassium chloride 10 mEq bid
5. Zolpidem tartrate 10 mg daily at h.s.
6. Lisinopril 10 mg daily
1. A psychotropic medication is one that affects the mind, emotions, or behavior. Research has shown that psychotropic medications are associated with risk of falls in older adult clients. Alprazolam (Xanax XR), a benzodiazepine prescribed to control anxiety, can contribute to a fall.
5. Zolpidem tartrate (Ambien), a hypnotic prescribed for short-term insomnia, is considered a psychotropic medication. Its use can contribute to risk for a fall.
The nurse assesses the client returning from a coronary angiogram in which the femoral artery approach was used. The client’s baseline BP during the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication?
1. BP 154/78 mm Hg
2. Pedal pulses palpable at +1
3. Left groin soft to palpation with 1 cm ecchymotic area
4. Apical pulse 132 beats per minute (bpm) with an irregular–irregular rhythm
4. An apical pulse of 132 bpm with an irregular–irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram.
The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse’s best immediate intervention?
1. Administer the insulin that is due now.
2. Call the lab for a STAT serum glucose level.
3. Have the client choose foods for a meal now.
4. Provide juice with 15 grams of carbohydrates.
4. Normal blood glucose level is 70–110 mg/dL. Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.
The nurse is teaching newly hired NAs in a long-term care facility. What information about skin care for older adults should the nurse emphasize?
1. Avoid skin products purchased for the resident by family that contain alcohol.
2. Apply perfumed skin lotions after the resident’s bath when the skin is still moist.
3. When taking residents outdoors, apply sunscreen with a sun protection factor of 8.
4. Apply a strong detergent to clothing with food stains before sending to laundry.
1. The nurse should emphasize avoiding skin products containing alcohol, which is drying to the skin. Age-related skin changes of the elderly include dry and fragile skin.
The nurse has prepared medications for a 75-year-old client with hypertension. The nurse notes that the client has an elevated serum potassium level. Which medication is most important for the nurse to address with the HCP before administration?
1. Lisinopril 40mg Oral Tablet
2. Metoprolol 25 mg Oral Tablet
3. Atorvastatin 20mg Oral tablet
4. Sertraline 25mg Oral tablet
1. Hyperkalemia can occur as a side effect to lisinopril (Prinivil, Zestril), an ACE inhibitor. The HCP should be notified prior to administration. The drug or dose may need to be changed; 40 mg is the maximum daily dose for an elderly client.
The nurse is interviewing a family member of the hospitalized 90-year-old client to assess for common problems associated with an increased risk for falling. Which questions should the nurse ask? Select all that apply.
1. “Has your mother fallen within the past year?”
2. “Has your mother had her annual influenza vaccine?”
3. “When was the last time your mother took a pain pill?”
4. “Does your mother have any problems with urination?”
5. “Does your mother have difficulty falling asleep at night?”
1. Asking if the client has fallen in the last year will help determine if the client has a history of falls and the risk level for a fall.
3. Analgesics can contribute to dizziness and increase the risk for falling.
4. Asking about elimination will help determine if the client has problems with incontinence or urgency. Needing to hurriedly use the bathroom can increase the risk for falling.
5. Asking about the client’s nighttime sleep will help determine if the client has any sleep disorders that could contribute to night-time wandering and the risk for falling.
The nurse is assessing the client following an inferior-septal wall MI. Which potential complication should the nurse further explore when noting that the client has jugular venous distention (JVD) and ascites?
1. Left-sided heart failure
2. Pulmonic valve malfunction
3. Right-sided heart failure
4. Ruptured septum
3. Right-sided HF produces venous congestion in the systemic circulation, resulting in JVD and ascites (from vascular congestion in the GI tract). Additional signs include hepatomegaly, splenomegaly, and peripheral edema.
The nurse is completing a variance report after finding an error for the client who is to receive an IV infusion of heparin at 1000 units/hour. Heparin 25,000 units in 500 mL D5W is infusing at 30 mL/hr. At what rate should the nurse record that the heparin should be infusing? __________ mL/hr (Record your answer as a whole number.)
Based on the concentration, the pump should be set at 20 mL/hr.
The nurse completes discharge teaching for the client with chronic stage 2 hypertension. Which statement by the client indicates that teaching was effective?
1. “I will limit my intake of potassium.”
2. “I will start a rigorous exercise program now.”
3. “I will call my provider if my vision blurs.”
4. “I will strive to maintain my BMI at 32.”
3. Teaching is effective if the client states to call the HCP immediately if experiencing vision changes. Sudden vision changes may be associated with stroke, a complication of hypertension.
The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0. 9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?
1. A low-calorie regular diet
2. A statin antilipidemic medication
3. A thiazide diuretic medication
4. Low-salt, low-saturated-fat, low-potassium diet
2. A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will lower the LDL cholesterol and triglycerides and increase the HDL cholesterol.
The nurse manager is observing care for the older adult client. Which observations require the nurse manager to intervene because it increases the client’s risk for developing skin breakdown? Select all that apply.
1. The NA applies a perfumed lotion to the client’s skin.
2. Two NAs are elevating the client’s heels off the bed.
3. A family member brings the client custard from home.
4. The nurse applies an alcohol-based hand wash to the client’s hands.
5. The nurse tells the client to push with the heels to move up in bed.
1. Perfumed lotion increases skin irritation and can lead to skin breakdown.
4. Alcohol-based hand wash is drying and can increase skin irritation and lead to skin breakdown.
5. Using the heels to reposition in bed causes friction and sheer and increases the risk for skin breakdown.
The nurse is planning to complete noon assessments for four assigned clients with type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse’s assessment.
1. The 60-year-old client who is nauseated and has just vomited for the second time
2. The 45-year-old client who is dyspneic and has chest pressure and new-onset atrial fibrillation
3. The 75-year-old client with a fingerstick blood glucose level of 300 mg/dL
4. The 50-year-old client with a fingerstick blood glucose level of 70 mg/dL
2, 1, 3, 4
Client
55-year old male
Allergies
Cefuroxime
Admitting Diagnosis
Left femoral neck fracture 72 hours ago
Surgery
Left total hip arthroplasty, anterior approach, 24 hours ago
Medical History
Hyperlipidemia, hypertension, depression
Laboratory Test Results
Complete blood count: Hemoglobin 16.6 g/dL (166 g/L), platelets 450×103/microL (450,000/mm3), WBC 10.1×103/microL (10,100/mm3)
Serum Chemistry: Sodium 143 mEq/L (143 mmol/L), potassium 4.8 mEq/L (4.8 mmol/L), creatinine 1.2 mg/dL (106.1 Mmol/L), BUN 18 mg/dL (6.4 mmol/L)
Coagulation: PT 12 seconds, APTT 32 seconds
Diet
Low sodium, low saturated fat
Scheduled Procedures
Left hip x-ray in 30 minutes
Current Vital Signs
BP 146/92; pulse 46; respirations 20; oral temperature 99°F (37.2°C)
Medications Due at This Time
Cefazolin 500 mg IVPB
Enoxaparin 30 mg subcutaneously
Hydrocodone/acetaminophen 5 mg/325 mg 1 tab orally
Metoprolol succinate 100 mg orally
Pantoprazole 40 mg orally
Olanzapine 100 mg orally
The nurse is preparing to administer scheduled medications to the client. Which three medications would require clarification before administration?
1. Cefazolin
A. The serum creatinine and BUN is elevated.
2. Enoxaparin
B. The client has an allergy to a cephalosporin antibiotic.
3. Hydrocodone/acetaminophen
C. The client has bradycardia.
4. Metoprolol succinate
D. The client has thrombocytopenia.
5. Pantoprazole
E. The dose is too high.
6. Olanzapine
F. The client has hyperkalemia.
1B, 4C, 6E
The nurse assesses the client who recently had a lower lobectomy for lung cancer. Findings include dyspnea with respirations at 45 bpm, hypotension, SaO2 at 86% on 10 L close-fitting oxygen mask, trachea deviated slightly to the left, and the right side of the client’s chest not expanding. Which action should be taken by the nurse first?
1. Notify the client’s HCP.
2. Give the prn prescribed lorazepam.
3. Check the chest tube for obstruction.
4. Increase the oxygen flow to 15 liters.
3. Tracheal deviation and the other signs and symptoms suggest a tension pneumothorax, which can occur from obstruction of the tubing. The chest tube tubing should be checked for kinks and the chest tube collection system for blockage.
The nurse reviews the client’s laboratory results exhibited. Which findings, indicative of an MI, should the nurse report to the HCP?
Laboratory TestsClient Results
SCr (0.4–1.4 mg/dL)
1.8
BUN (10–20 mg/dL)
30
Potassium (3.8–5.3 mEq/L)
5.8
Mg (1.7–2.2 mg/dL)
1.6
CK-MB (0–16 units/L)
32
Troponin T (cTnT) (0.0–0.4 ng/mL)
34
WBC (3.9–11.9 K/microL or mm3)
14
Platelets (Pit 179-450 K/microL or mm3)
175
PT (9.2–11.9 sec)
22
INR (0.9–1.1 sec)
2.2
The CK-MB band is specific to myocardial cells and increases with myocardial injury. Cardiospecific troponins (troponin T [cTnT] and troponin I [cTnI]) are released into circulation after myocardial injury, are highly specific indicators of MI, and have greater sensitivity and specificity than CK-MB.
The home health nurse suspects elder mistreatment of the 93-year-old client by the live-in caregiver. Which findings support the nurse’s conclusion? Select all that apply.
1. The client has urine burns.
2. The client has wrist bruises.
3. The client states that there have been some unexplained financial expenditures.
4. The client is more talkative than during previous home visits.
5. The smell of alcohol is noted on the live-in caregiver’s breath.
1. Urine burns suggest caregiver neglect by not assisting the client to the toilet or changing the client if incontinent.
2. Wrist bruises suggest physical abuse that may be caused by physically restraining the client.
3. Unexplained financial expenditures suggest financial exploitation and use of funds for personal use by the caregiver.
5. Substance abuse is an abuser characteristic.