Adult Health 2 Final Exam

Questions 48

HESI LPN

HESI LPN Test Bank

Adult Health 2 Final Exam Questions

Question 1 of 5

A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?

Correct Answer: B

Rationale: Reporting signs of bleeding is essential while on anticoagulant therapy to prevent complications.

Question 2 of 5

A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)

Correct Answer: D

Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.

Question 3 of 5

A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?

Correct Answer: C

Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.

Question 4 of 5

The nurse is caring for a client with a diagnosis of bipolar disorder who is taking lithium. What is the most important information the nurse should provide?

Correct Answer: B

Rationale: The correct answer is B: 'Monitor sodium intake.' Sodium levels can affect lithium levels in the body, so it is crucial to maintain a consistent sodium intake to prevent toxicity or subtherapeutic levels. Option A is incorrect because lithium is usually recommended to be taken on an empty stomach to enhance absorption. Option C, reporting signs of weight gain, is relevant but not as critical as monitoring sodium intake. Option D, avoiding excessive caffeine intake, is important for some individuals but not as essential as monitoring sodium levels when taking lithium.

Question 5 of 5

The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. What response should the nurse provide first?

Correct Answer: B

Rationale: Choice B is the correct answer as it accurately explains that the letters T, N, and M in cancer staging represent tumor size, node involvement, and metastasis, respectively. Understanding this staging system helps the client comprehend the extent and severity of the disease. Choices A, C, and D are incorrect. Choice A has the correct information but is not the most precise response. Choice C is vague and does not directly address the client's need for clarification. Choice D offers further clarification without directly addressing the initial explanation provided by the healthcare provider.

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