Question

A nurse in a primary care clinic is caring for a client who is 65 years old with a BMI (body mass index) of 31. What information should the nurse to the client concerning his fasting blood glucose level of 147 mg/dL?

Answer 1

Correct Answers:

"The healthcare provider will want to repeat testing on another day, because your fasting blood glucose was higher than it should be."

Rationale :

🩸A fasting blood glucose of 147 mg/dL is higher than the expected normal fasting range.

📊A fasting glucose level of 126 mg/dL or higher suggests possible diabetes mellitus.

🔁The diagnosis usually requires repeat testing on another day to confirm the finding.

⚖️The client’s age and BMI of 31 increase the risk for type 2 diabetes.

📌Core Message

A fasting glucose of 147 mg/dL is elevated and should be retested to confirm possible diabetes.

Answer 2

Correct Answers:

All of these

Rationale :

🧬A history of inflammatory bowel disease increases colon cancer risk due to chronic intestinal inflammation.

👨‍👩‍👧A family history of colorectal polyps or cancer increases inherited or familial risk.

🚬Tobacco use is associated with increased risk for several cancers, including colon cancer.

🍷Alcohol consumption can also contribute to increased colorectal cancer risk.

📌Core Message

Colon cancer risk increases with IBD, family history, tobacco use, and alcohol consumption.

Answer 3

Correct Answers:

Weight loss

Rationale :

⚖️Weight loss improves insulin sensitivity in clients with type 2 diabetes.

🍬Improved insulin sensitivity helps glucose move from the bloodstream into body cells more effectively.

🏃Lifestyle changes such as weight reduction and activity can lower blood glucose levels.

🩺For overweight clients, even modest weight loss can significantly improve glycemic control.

📌Core Message

For overweight clients with type 2 diabetes, weight loss has a major impact on improving blood glucose control.

Answer 4

Correct Answers:

All of these

Rationale :

👵Age increases urinary incontinence risk because pelvic muscles and bladder function can weaken over time.

🚬Smoking can contribute to chronic coughing, which increases pressure on the pelvic floor.

🌸Menopause lowers estrogen levels, which can weaken urethral and pelvic tissue support.

🧪Kidney or renal disease can affect urine production and urinary control.

📌Core Message

Urinary incontinence risk increases with age, smoking, menopause, and renal disease.

Answer 5

Correct Answers:

While you cannot control some risk factors, there are others that you can control.

Rationale :

🫀The client’s results show abnormal cholesterol levels, including elevated total cholesterol and LDL.

📉A low HDL level is concerning because HDL helps remove excess cholesterol from the bloodstream.

💬The nurse’s response supports the client emotionally while encouraging focus on modifiable risk factors.

🥦Lifestyle changes can help improve lipid levels and reduce cardiovascular risk.

📌Core Message

The best response acknowledges concern and focuses on improving modifiable cardiovascular risk factors.

Answer 6

Correct Answers:

Hepatitis B for a client with hypersensitivity to yeast

Rationale :

💉Hepatitis B vaccine is produced using yeast, so a client with yeast hypersensitivity is at risk for a serious allergic reaction.

⚠️Hypersensitivity to vaccine components is a major reason the nurse should question vaccine administration before giving the dose.

🛡️The nurse must verify allergy history carefully because vaccine reactions can progress to anaphylaxis in susceptible clients.

📋Questioning this prescription supports client safety and prevents administration of a vaccine that is contraindicated for the client.

📌Core Message

Yeast hypersensitivity is a contraindication to hepatitis B vaccination because it can trigger a serious allergic reaction.

Answer 7

Correct Answers:

Decreased blood pressure

Rationale :

💊Lisinopril is an ACE inhibitor used to treat hypertension.

📉A therapeutic effect is shown by a decrease in blood pressure.

🫀Lower blood pressure reduces strain on the heart and blood vessels.

🧾The nurse should monitor blood pressure to evaluate medication effectiveness and safety.

📌Core Message

The therapeutic effect of lisinopril is decreased blood pressure.

Answer 8

Correct Answers:

The infant's anterior fontanel is bulging

Rationale :

👶A bulging anterior fontanel in a newborn can indicate increased intracranial pressure.

🧠This finding is concerning because it may reflect neurologic or infectious complications.

🚨The nurse should report this finding promptly to the primary care provider.

🍼Normal findings include frequent breastfeeding, stooling after feeds, and small spit-ups after feeding.

📌Core Message

A bulging anterior fontanel is abnormal and may signal increased intracranial pressure.

Answer 9

Correct Answers:

Progressive loss of hearing
Decreased cough reflex
Decreased bladder capacity
Dehydration of intervertebral discs

Rationale :

👂Progressive hearing loss is common in older adults due to age-related changes in the auditory system.

💁‍♂️A decreased cough reflex increases the risk for aspiration and respiratory complications in older adult clients.

🚻Decreased bladder capacity can contribute to urinary frequency, urgency, and nocturia in aging clients.

🦴Dehydration of intervertebral discs causes loss of disc height and can contribute to decreased height and posture changes.

📌Core Message

Older adults commonly experience hearing loss, reduced cough reflex, decreased bladder capacity, and disc dehydration as part of normal aging.

Answer 10

Correct Answers:

The establishment of trust

Rationale :

🤝The first step in a health history interview is establishing trust and rapport.

💬Trust helps the client feel safe sharing accurate and personal health information.

🧑‍⚕️A respectful introduction and professional communication support a strong nurse-client relationship.

📋Once trust is established, the nurse can collect the chief complaint and history more effectively.

📌Core Message

A health history interview begins with trust, which supports accurate and open communication.

Health Promotion & Maintenance

No.

1 :
A nurse in a primary care clinic is caring for a client who is 65 years old with a BMI (body mass index) of 31. What information should the nurse to the client concerning his fasting blood glucose level of 147 mg/dL?

2 :
A nurse is caring for a client who asks about risk factors for colon cancer. Which of the following increases the risk of colon cancer?

3 :
A nurse is providing diabetic teaching to an overweight client who was recently diagnosed with type 2 diabetes. What has the greatest impact on normal blood glucose levels?

4 :
A wound, ostomy and continence nurse (WOCN) screens women who are incontinent of urine to determine the appropriate plan of care. The nurse knows that risk factors for urinary incontinence include which of the following?

5 :
A nurse is caring for a client in a physician's office who has new laboratory test results that reveal total cholesterol 230 mg/dL, HDL 30 mg/dL, and LDL 156 mg/dL. The client states, "I am so upset about these results." Which of the following would be the nurse's most appropriate response?

6 :
A nurse who is employed in a community outpatient clinic should question which of the following prescriptions for vaccine administration?

7 :
A nurse is assessing a client who is taking lisinopril. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication?

8 :
A nurse is performing an initial home visit to an infant born 3 days ago. Which of the following findings should prompt the nurse to speak to the primary care provider who is caring for the mother and infant?

9 :
A nurse is conducting a comprehensive physical examination of an older adult client. Which of the following age-related changes should the nurse consider when assessing this client? (Select all that apply.)

10 :
The first step of a health history interview is:

Health Promotion & Maintenance

No.

1 : A nurse in a primary care clinic is caring for a client who is 65 years old with a BMI (body mass index) of 31. What information should the nurse to the client concerning his fasting blood glucose level of 147 mg/dL?

2 : A nurse is caring for a client who asks about risk factors for colon cancer. Which of the following increases the risk of colon cancer?

3 : A nurse is providing diabetic teaching to an overweight client who was recently diagnosed with type 2 diabetes. What has the greatest impact on normal blood glucose levels?

4 : A wound, ostomy and continence nurse (WOCN) screens women who are incontinent of urine to determine the appropriate plan of care. The nurse knows that risk factors for urinary incontinence include which of the following?

5 : A nurse is caring for a client in a physician's office who has new laboratory test results that reveal total cholesterol 230 mg/dL, HDL 30 mg/dL, and LDL 156 mg/dL. The client states, "I am so upset about these results." Which of the following would be the nurse's most appropriate response?

6 : A nurse who is employed in a community outpatient clinic should question which of the following prescriptions for vaccine administration?

7 : A nurse is assessing a client who is taking lisinopril. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication?

8 : A nurse is performing an initial home visit to an infant born 3 days ago. Which of the following findings should prompt the nurse to speak to the primary care provider who is caring for the mother and infant?

9 : A nurse is conducting a comprehensive physical examination of an older adult client. Which of the following age-related changes should the nurse consider when assessing this client? (Select all that apply.)

10 : The first step of a health history interview is:

1 :
A nurse in a primary care clinic is caring for a client who is 65 years old with a BMI (body mass index) of 31. What information should the nurse to the client concerning his fasting blood glucose level of 147 mg/dL?

2 :
A nurse is caring for a client who asks about risk factors for colon cancer. Which of the following increases the risk of colon cancer?

3 :
A nurse is providing diabetic teaching to an overweight client who was recently diagnosed with type 2 diabetes. What has the greatest impact on normal blood glucose levels?

4 :
A wound, ostomy and continence nurse (WOCN) screens women who are incontinent of urine to determine the appropriate plan of care. The nurse knows that risk factors for urinary incontinence include which of the following?

5 :
A nurse is caring for a client in a physician's office who has new laboratory test results that reveal total cholesterol 230 mg/dL, HDL 30 mg/dL, and LDL 156 mg/dL. The client states, "I am so upset about these results." Which of the following would be the nurse's most appropriate response?

6 :
A nurse who is employed in a community outpatient clinic should question which of the following prescriptions for vaccine administration?

7 :
A nurse is assessing a client who is taking lisinopril. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication?

8 :
A nurse is performing an initial home visit to an infant born 3 days ago. Which of the following findings should prompt the nurse to speak to the primary care provider who is caring for the mother and infant?

9 :
A nurse is conducting a comprehensive physical examination of an older adult client. Which of the following age-related changes should the nurse consider when assessing this client? (Select all that apply.)

10 :
The first step of a health history interview is: