Adult Health Nursing Flashcards

A patient with type 2 diabetes has a fasting blood glucose of 320 mg/dL. Which symptom is most likely present?

Answer: Polyuria, polydipsia, and polyphagia

The classic triad of hyperglycemia is polyuria (excess urination), polydipsia (excess thirst), and polyphagia (excess hunger). At 320 mg/dL the osmotic diuretic effect of glucose spills into urine, driving fluid loss and thirst.

Which assessment finding is most characteristic of left-sided heart failure?

Answer: Pulmonary congestion with dyspnea and crackles

The left ventricle pumps blood to the systemic circulation. When it fails, blood backs up into the pulmonary circulation, causing pulmonary edema, dyspnea, orthopnea, and crackles on auscultation.

A patient is admitted with suspected myocardial infarction. Which laboratory marker is most specific for cardiac muscle damage?

Answer: Troponin I or Troponin T

Cardiac troponins (troponin I and T) are highly specific biomarkers for myocardial cell injury. They rise within 3–6 hours of infarction, peak at 12–24 hours, and remain elevated for 7–10 days, making them the gold standard diagnostic marker.

What is the priority nursing intervention for a patient experiencing a tonic-clonic seizure?

Answer: Protect the patient from injury, maintain airway, do not restrain

The priority during a seizure is patient safety: lower to the floor if possible, cushion the head, clear the environment, and turn to the side after convulsive activity stops to maintain airway. Never restrain or insert objects in the mouth.

A patient has a serum potassium of 2.8 mEq/L. Which ECG finding is expected?

Answer: Flattened T waves and U waves

Hypokalemia (K+ <3.5 mEq/L) causes flattened or inverted T waves and the appearance of U waves (a positive deflection after the T wave) on ECG. Severe hypokalemia can lead to life-threatening dysrhythmias.

Which position is contraindicated for a patient who has just had a lumbar puncture?

Answer: Sitting upright immediately after the procedure

After lumbar puncture, patients typically lie flat for 4–8 hours to reduce the risk of post-lumbar puncture headache caused by CSF leakage. Sitting upright too soon increases intracranial pressure gradient and worsens CSF leakage.