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NURS 340 EXAM 1, HEALTH ASSESSMENT EXAM 1
AND STUDY GUIDE||2025-2026|| ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED
ANSWERS||A+ GRADE
A client with diabetes is learning to mix regular insulin and NPH insulin in the same syringe; the caregiver determines that additional teaching is needed when the client does what - ...ANS:>>>>...withdraws the NPH dose into the syringe first The following interventions are planned for a diabetic client; which intervention can the caregiver delegate to unlicensed assistive personnel - ...ANS:>>>>...check that the bath water is not too hot The home care caregiver should intervene to correct a client whose insulin administration includes - ...ANS:>>>>...mixing an evening dose of regular insulin with insulin glargine in one syringe for administration When teaching the client with type 1 diabetes, what should the caregiver emphasize as the major advantage of using an insulin pump - ...ANS:>>>>...tight glycemic control can be maintained A client taking insulin has recorded fasting glucose levels above 200 mg/dL on awakening for the last five mornings;
What should the caregiver advise the client to do first - ...ANS:>>>>...monitor the glucose level at bedtime, between 2 and 4am, and on arising which class of oral glucose-lowering agents is most commonly used for people with type 2 diabetes because it reduces hepatic glucose production and enhances tissue uptake of glucose - ...ANS:>>>>...biguinide the client with type 2 diabetes is being put on acarbose (precose) and wants to know why she is taking it; what should the caregiver include in this client's teaching - ...ANS:>>>>...take it with the first bite of each meal; effectiveness is measured by 2 - hour postprandial glucose; it delays glucose absorption from the gastrointestinal tract the caregiver is assessing a newly admitted diabetic client; which observation should be addressed as the priority by the caregiver - ...ANS:>>>>...rapid respirations with deep inspiration individualized nutrition therapy for clients using conventional, fixed insulin regimens should include teaching the client to - ...ANS:>>>>...eat regular meals at regular times what should the goals of nutrition therapy for the client with type 2 diabetes include - ...ANS:>>>>...normal serum glucose and lipid levels to prevent hyperglycemia or hypoglycemia related to exercise, what should the caregiver teach the client using glucose- lowering agents about the best time for exercise -
dehydration
the client with newly diagnosed diabetes is displaying shakiness, confusion, irritability, and slurred speech; what should the caregiver suspect is happening - ...ANS:>>>>...hypoglycemia the client with diabetes has a blood glucose level of 248 mg/dL; which manifestations in the client would the caregiver understand as being related to this blood glucose level - ...ANS:>>>>...headache, abdominal cramps, increase in urination, weakness and fatigue a diabetic client is found unconscious at home and a family member calls the clinic; after determining that a glucometer is not available, what should the caregiver advise the family member to do - ...ANS:>>>>...administer glucagon 1 mg intramuscularly or subcutaneously the client with diabetes is brought to the emergency department by his family members, who say that he is not acting like himself and he is more tired than usual; what would be the order of the nursing actions for this client - ...ANS:>>>>...ensure patent airway; check blood glucose; establish IV access; administer 0.9% NaCl solution at 1L/hr; begin continuous regular insulin drip; establish time of las food and medication(s) two days following a self-managed hypoglycemic episode at home, the client tells the caregiver that his blood glucose levels since the episode have been between 80 and 90 mg/dL; which is the best response by the caregiver - ...ANS:>>>>..."that is a good range for your glucose levels"
the assessment identify the presence of spinal shock - ...ANS:>>>>...tetraplegia with total sensory loss which syndrome of incomplete spinal cord lesion is described as cord damage common in the cervical region resulting in greater weakness in upper extremities than lower - ...ANS:>>>>...central cord syndrome the client is diagnosed with Brown-Séquard syndrome after a knife wound to the spine; which description accurately describes this syndrome - ...ANS:>>>>...spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the level of the lesion what causes an initial incomplete spinal cord injury to result in complete cord damage - ...ANS:>>>>...infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites a client with spinal cord injury has spinal shock; the caregiver plans care for the client based on what knowledge - ...ANS:>>>>...resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder two days following a spinal cord injury, a client asks continually about the extent of impairment that will result from the injury; what is the best response by the caregiver - ...ANS:>>>>..."the extent of your injury cannot be determined until the secondary injury to the cord is resolved" the client was in a traffic collision and is experiencing loss of function below C4; which effect must the caregiver be aware
of to
during assessment of a client with a spinal cord injury, the caregiver determines that the client has a poor cough with diaphragmatic breathing; based on this finding, what should be the caregiver's first action - ...ANS:>>>>...assess lung sounds and respiratory rate and depth following a T2 spinal cord injury, the client develops paralytic ileus; while this condition is present, what should the caregiver anticipate that the client will need - ...ANS:>>>>...nasogastric suctioning how is urinary function maintained during the acute phase of spinal cord injury - ...ANS:>>>>...an indwelling catheter a week following a spinal cord injury at T2, a client experiences movement in his leg and tells the caregiver that he is recovering some function; what is the caregiver's best response to the client - ...ANS:>>>>..."that could be a really positive finding; can you show me the movement?" a client with a spinal cord injury suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury; after checking the client's vital signs and finding a systolic blood pressure of 210 and a heart rate of 48 bpm, what is the order of nursing actions from highest to lowest priority - ...ANS:>>>>...raise the HOB to 45 degrees or above; check for bladder distention; place call to physician; loosen tight clothing on the client; administer ordered prn nifedipine (procardia); document the occurrence, treatment, and response a client with paraplegia has developed an irritable bladder with reflex emptying; what will be most helpful for the caregiver
to teach the client - ...ANS:>>>>...how to perform intermittent self-catheterization in counseling clients with spinal cord lesions regarding sexual function, how should the caregiver advise a male client with a complete lower motor neuron lesion - ...ANS:>>>>...he will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm during the client's process of grieving for the losses resulting from spinal cord injury, what should the caregiver do - ...ANS:>>>>...help the client to understand that working through the grief will be a lifelong process a client with a metastatic tumor of the spinal cord is scheduled for removal of the tumor by a laminectomy; in planning postoperative care for the client, what should the caregiver recognize - ...ANS:>>>>...metastatic tumors are commonly extradural lesions that are treated palliatively which chronic neurologic disorder involves a deficiency of theneurotransmitters acetylcholine and GABA in the basal ganglia and extrapyramidial system - ...ANS:>>>>...Huntington's disease a 38-year-old woman has newly diagnosed MS and asks the caregiver what is going to happen to her; what is the best response by the caregiver - ...ANS:>>>>..."you will have either periods of attacks and remissions or progression of nerve damage over time" during assessment of a client admitted to the hospital with an acute exacerbation of MS, what should the caregiver expect to
during care of a client in myasthenic crisis, maintenance of what is the caregiver's first priority for the client - ...ANS:>>>>...respiratory function when providing care for a client with ALS, the caregiver recognizes what as one of the most distressing problems experienced by the client - ...ANS:>>>>...retention of cognitive function with total degeneration of motor function in the shift change of report, an off going caregiver criticizes a client who wears heavy makeup; which comment by the caregiver who received the report best demonstrates advocacy - ...ANS:>>>>...our clients need our help to learn behaviors that will help them get along in society which outcome, focused on recovery, would be expected in the plan of care for a client living in the community with serious and persistent mental illness; within 2 months, the client will - ...ANS:>>>>...report a sense of well-being a staff caregiver completes orientation to a psychiatric unit; the caregiver may expect an advanced practice caregiver to perform which additional assessment - ...ANS:>>>>...prescribe psychotropic medication which assessment finding most clearly indicates that a client may be experiencing a mental illness - ...ANS:>>>>...reports a consistently sad, discouraged mood which indicates that the goal "demonstrate mentally healthy behavior" was acheived - ...ANS:>>>>...sees self as capable of achieving ideals and meeting demands
a caregiver encounters an unfamiliar psychiatric disorder; which resource should the caregiver consult to determine criteria used to establish the diagnosis - ...ANS:>>>>...diagnostic and statistical manual of mental disorders (DSM5) a caregiver wants to find a description of diagnostic criteria for anxiety disorders; which resource would have the most complete information - ...ANS:>>>>...diagnostic and statistical manual of mental disorders (DSM5) which individual is demonstrating highest level of resilience; an individual who - ...ANS:>>>>...takes a temporary job to maintain financial stability after the loss of a job which Western cultural feature may result in establishing unrealistic outcomes for clients of other cultural groups - ...ANS:>>>>...direct confrontation to solve problems a Haitian client with depression tells the caregiver "there's nothing you can do; this is punishment"; what does this tell the caregiver - ...ANS:>>>>...the client may believe the distress is the result of a curse or spell a person diagnosed with schizophrenia has had difficulty keeping a job because of arguing with coworkers and accusing them of conspiracy; today the person shouts "they're all plotting to destroy me"; select the caregiver's most therapeutic response - ...ANS:>>>>...feeling that people want to destroy you must be very frightening a newly admitted client diagnosed with schizophrenia is hyper-vigilant and constantly scans the environment; he states "I saw two doctors talking in the hall; they were plotting to
the husband and daughter of a hispanic woman dying from pancreatic cancer refuse to consider using hospice care; what is the first thing the caregiver should do - ...ANS:>>>>...assess their understanding of what hospice care services are list the two criteria for admission to a hospice program - ...ANS:>>>>...client must desire services and agree in writing that only hospice care can be used to treat the terminal illness (palliative care); client must meet eligibility, which is less than six months to live, certified initially by two physicians what are some physical manifestations that the caregiver would expect to see in a client approaching death - ...ANS:>>>>...Cheyne-Stokes respiration; death rattle (inability to cough and clear secretions); increased, then slowing, respiratory rate; irregular breathing; terminal gasping; mottling on hands, feet, and legs that progresses to the torso; cold, clammy skin; cyanosis on nose, nail beds, and knees; waxlike skin; slowing of the GI tract with accumulation of gas and abdominal distention; loss of sphincter control with incontinence; bowel movement before imminent death or at time of death; loss of muscle tone with sagging jaw; difficulty speaking; difficulty swallowing; loss of ability to move or maintain body position; loss of gag reflex a terminally ill client is unresponsive and has cold, clammy skin with mottling on the extremities; the client's husband and two grown children are arguing at the bedside about where the client's funeral should be held; what should the caregiver do first - ...ANS:>>>>...take the family members aside and explain that the client may be able to hear them
a 20-year-old client with a massive head injury is on life support, including a ventilator to maintain respirations; what three criteria for brain death are necessary to discontinue life support - ...ANS:>>>>...coma, absent brainstem reflexes, apnea a client with end-stage liver failure tells the caregiver, "if I can just live to see my first grandchild who is expected in five months, then I can die happy"; the caregiver recognizes that the client is demonstrating which of the following stages of grieving - ...ANS:>>>>...Kübler-Ross's stage of bargaining a terminally ill man tells the caregiver, "I have never believed there is a God or an afterlife, but now it is too terrible to imagine that I will not exist; why was I here in the first place?" what does this comment help the caregiver recognize about the client's needs - ...ANS:>>>>...he is experiencing spiritual distress in most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents - ...ANS:>>>>...natural death acts a client is receiving care to manage symptoms of a terminal illness when the disease no longer responds to treatment; what is this type of care known as - ...ANS:>>>>...palliative care a client in the last stages of life is experiencing shortness of breath and air hunger; based on practice guidelines, what is the most appropriate action by the caregiver - ...ANS:>>>>...use any methods that make the client more comfortable
which laboratory results would indicate that the client has prediabetes - ...ANS:>>>>...fasting blood glucose result of 120 mg/dL the caregiver is teaching the client with prediabetes ways to prevent or delay the development of type 2 diabetes; what information should be included - ...ANS:>>>>...maintain a healthy weight; monitor for polyuria, polyphagia, and polydipsia in type 1 diabetes there is an osmotic effect of glucose when insulin deficiency prevents the use of glucose for energy; which classic symptom is caused by the osmotic effect of glucose - ...ANS:>>>>...polydipsia which client should the caregiver plan to teach how to prevent or delay the development of diabetes - ...ANS:>>>>...a 34-year- old woman whose parents both have type 2 diabetes when caring for a client with metabolic syndrome, what should the caregiver give the highest priority to teaching the client about - ...ANS:>>>>...achieving a normal weight during routine health screening, a client is found to have fasting plasma glucose of 132 mg/dL; at a follow-up visit, a diagnosis of diabetes would be made based on which laboratory results - ...ANS:>>>>...A1C of 7.5%; FPG > 126 mg/dL the caregiver determines that a client with a 2-hour OGTT of 152 mg/dL has - ...ANS:>>>>...impaired glucose tolerance
when teaching the client with diabetes about insulin administration, the caregiver should include which instruction for the client - ...ANS:>>>>...consistently use the same size of insulin syringe to avoid dosing errors a client with type 1 diabetes uses 20 units of 70/ NPH/regular in the morning and at 6pm; when teaching the client about this regimen, what should the caregiver emphasize - ...ANS:>>>>...a set meal pattern with a bedtime snack is necessary to prevent hypoglycemia Lispro insulin (Humalog) with NPH insulin is ordered for a client with newly diagnosed type 1 diabetes; the caregiver knows that when lispro insulin is used, when should it be administered - ...ANS:>>>>...at mealtime or within 15 minutes of meals in providing care for clients with chronic, progressive neurologic disease, what is the major goal of treatment that the caregiver works toward - ...ANS:>>>>...maximize neurologic functioning for as long as possible in promoting health maintenance for prevention of strokes, the caregiver understands that the highest risk for the most common type of stroke is present in which people - ...ANS:>>>>...individuals with hypertension and diabetes a thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because - ...ANS:>>>>...circulation via the circle of Willis may provide blood supply to the affected area of the brain
