Adult Health 1 Final Exam

Adult Health 1 Final Exam Related

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Which client is at the highest risk for developing pressure ulcers?

  • A. A 50-year-old client with a fractured femur
  • B. A 30-year-old client with diabetes mellitus
  • C. A 65-year-old client with limited mobility
  • D. A 70-year-old client with a history of stroke
Correct Answer: C

Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.

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The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?

  • A. Take the medication with or without food.
  • B. Report any increase in suicidal thoughts.
  • C. Avoid foods high in tyramine.
  • D. Expect improvement within 24 hours.
Correct Answer: B

Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.

A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?

  • A. Increase intake of green leafy vegetables
  • B. Maintain a consistent intake of vitamin K-rich foods
  • C. Avoid all foods containing vitamin K
  • D. Consume a high-protein diet
Correct Answer: B

Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.

A client with a diagnosis of chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). What is the primary goal of this medication?

  • A. To reduce the risk of bleeding.
  • B. To lower blood pressure.
  • C. To stimulate red blood cell production.
  • D. To increase appetite.
Correct Answer: C

Rationale: The correct answer is C: 'To stimulate red blood cell production.' Epoetin alfa, such as Epogen, is used to treat anemia by stimulating red blood cell production in clients with chronic kidney disease. This medication helps increase hemoglobin levels and reduce the need for blood transfusions. Option A, 'To reduce the risk of bleeding,' is incorrect as epoetin alfa does not directly impact bleeding risk. Option B, 'To lower blood pressure,' is incorrect as epoetin alfa is not indicated for blood pressure management. Option D, 'To increase appetite,' is also incorrect as the primary goal of epoetin alfa is related to improving anemia by boosting red blood cell production.

Which membrane lines the abdominal cavity?

  • A. Perineum
  • B. Pericardium
  • C. Pleura
  • D. Peritoneum
Correct Answer: D

Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.

A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?

  • A. Decreased sexual libido
  • B. Amenorrhea
  • C. Quickening
  • D. Nocturia
Correct Answer: B

Rationale: Amenorrhea is the absence of menstrual periods and is a common early sign of pregnancy, typically reported by a client who is 6 weeks pregnant. Decreased sexual libido (Choice A) may or may not be experienced in early pregnancy, but it is not as specific as amenorrhea. Quickening (Choice C) refers to fetal movements felt by the mother, which usually occurs around 18-20 weeks of pregnancy, not at 6 weeks. Nocturia (Choice D) is waking up at night to urinate and is not typically associated with early pregnancy.

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