Adult Health Exam 1

Adult Health Exam 1 Related

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An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?

  • A. Tell the client to keep her belongings because she will need them at discharge
  • B. Ask the client if she has had any recent thoughts of harming herself
  • C. Reassure the client that the antidepressant drugs are apparently effective
  • D. Support the client by telling her what wonderful progress she is making
Correct Answer: B

Rationale: In this scenario, the nurse should ask the client if she has had any recent thoughts of harming herself. Sudden mood improvements and behavioral changes, like giving away belongings, can be concerning signs of possible suicidal ideation. Assessing for suicidal thoughts is crucial to ensure the client's safety. Choice A is incorrect as it does not address the potential risk of harm or assess for suicidal ideation. Choice C is incorrect because simply reassuring the client about the effectiveness of antidepressants does not address the immediate concern of suicidal ideation. Choice D is incorrect as it focuses on praising progress without addressing the potential risk of harm the client may pose to herself.

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Which nonfood item is the most common cause of respiratory arrest in young children?

  • A. Broken rattles
  • B. Buttons
  • C. Pacifiers
  • D. Latex balloons
Correct Answer: D

Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.

A client with type 1 diabetes mellitus is learning to administer insulin. What is the best site for the nurse to recommend for insulin injection?

  • A. Abdomen
  • B. Thigh
  • C. Upper arm
  • D. Buttock
Correct Answer: A

Rationale: The correct answer is the abdomen. The abdomen is the recommended site for insulin injection due to its faster absorption rate compared to other sites. Insulin injected into the abdomen is absorbed more quickly, leading to better glycemic control. The thigh and upper arm are also common sites for insulin injection, but they have slower absorption rates than the abdomen. The buttock is not a preferred site for insulin injection due to inconsistent absorption and potential risk of injecting into muscle instead of fatty tissue.

A client with a diagnosis of hypothyroidism is prescribed levothyroxine (Synthroid). What is the most important instruction the nurse should provide?

  • A. Take the medication in the morning on an empty stomach
  • B. Take the medication with food
  • C. Report any symptoms of hyperthyroidism
  • D. Do not discontinue the medication abruptly
Correct Answer: C

Rationale: The correct answer is C: 'Report any symptoms of hyperthyroidism.' Symptoms of hyperthyroidism, such as palpitations or tremors, may indicate an excessive dose of levothyroxine and should be reported to the healthcare provider for proper adjustment of the medication. Choice A is incorrect because levothyroxine is usually taken in the morning on an empty stomach to maximize absorption. Choice B is incorrect because taking levothyroxine with food can interfere with its absorption. Choice D is incorrect because discontinuing levothyroxine abruptly can lead to a worsening of hypothyroidism symptoms.

The nurse is providing preoperative teaching to a client who will undergo a thyroidectomy. What information should the nurse include about postoperative care?

  • A. Importance of maintaining neck stability
  • B. How to care for the surgical drain
  • C. Pain management strategies
  • D. All of the above
Correct Answer: D

Rationale: Providing preoperative teaching for a client undergoing a thyroidectomy is essential to prepare them for postoperative care. Information about the importance of maintaining neck stability is crucial to prevent complications such as strain on the surgical site. Teaching the client how to care for the surgical drain is important to prevent infections, ensure proper wound healing, and aid in monitoring postoperative recovery. Pain management strategies are vital to ensure the client's comfort and promote optimal recovery. Including all these aspects in preoperative teaching ensures the client is well-prepared for comprehensive postoperative care. Therefore, the correct answer is D because all these elements are essential components of postoperative care for a client undergoing a thyroidectomy. Choices A, B, and C are all important aspects of postoperative care that the nurse should include in the preoperative teaching session.

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?

  • A. Use oxygen at the highest flow rate tolerated.
  • B. Do not smoke while using oxygen.
  • C. Avoid wearing the oxygen during physical activity.
  • D. Store oxygen tanks in a cool, dark place.
Correct Answer: B

Rationale: The most important instruction the nurse should provide to a client with COPD receiving home oxygen therapy is not to smoke while using oxygen. Smoking near oxygen can cause a fire or explosion due to the flammable nature of oxygen. Choice A is incorrect because using oxygen at the highest flow rate tolerated without medical supervision can be harmful. Choice C is the correct answer as wearing oxygen during physical activity can increase the risk of oxygen combustion. Choice D is not the most important instruction; while storing oxygen tanks properly is essential, the immediate safety concern is the risk of fire due to smoking near oxygen.

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