Ch. 22, 23, 42, 43

Clients with methicillin-resistant Staphylococcus aureus infections should be treated with _____________________________________ if the infection is severe.

oral linezolid or clindamycin or intravenous vancomycin

An adhesive clear film dressing provides protection for

partial-thickness lesions such as stage II pressure injuries.

Pitting is found in clients with

psoriasis or alopecia areata.

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? (Select all that apply.) "A tanning bed will supply the ultraviolet light I need." "Medicine can prevent the growth of new skin cells." "I can never be cured." "Stress can cause my flare-ups." "I am glad that this drug therapy will cure my condition."

"A tanning bed will supply the ultraviolet light I need." "I am glad that this drug therapy will cure my condition." Use of commercial tanning beds is specifically not recommended for clients. Psoriasis is a lifelong disorder and cannot be cured. These statements indicate that the client requires further teaching.Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis.

The nurse is educating a client who is to undergo a Wood Lamp examination. What teaching will the nurse provide? (Select all that apply.) "This examination requires a small injection of lidocaine." "Certain kinds of skin infections can be visualized." "Take ibuprofen before the examination to minimize pain." "An antibiotic ointment needs to be applied after the exam." "You will be in a darkened room while the provider uses the lamp."

"Certain kinds of skin infections can be visualized." "You will be in a darkened room while the provider uses the lamp." Certain skin infections can be seen using a Wood Lamp, which produces a specific color, such as blue-green or red, that can be used to identify infection. Hypopigmented skin is more prominent when it is viewed under black light, making evaluation of pigment changes in lighter skin easier. This examination is carried out in a darkened room and does not cause discomfort. Lidocaine, ibuprofen, and an antibiotic ointment are not needed.

A client with a bacterial skin infection is being taught home care for treatment of this infection. Which statement by the client indicates a need for further teaching? "I may stop using the topical antibiotic when the lesions disappear." "I will remove crusts with soap and water before applying the medication." "I should contact my provider if I develop a fever or if the lesions spread. "I should cover the lesions if necessary to limit exposure to other people."

"I may stop using the topical antibiotic when the lesions disappear." The statement by the client that, "I may stop using the topical antibiotic when the lesions disappear," indicates the need for further teaching. The antibiotic should be used for the time prescribed and not just until the lesions seem to be resolved.Clients should be taught to remove crusts before applying the medication to improve absorption. If signs of systemic disease occur, the client should contact the provider since oral antibiotics may be necessary. Covering the lesions will help prevent spread to others.

kg to lbs

1 kg = 2.2 lbs

A nurse is teaching a community group about preventing hearing loss. What instruction is appropriate? a. "Always wear a bicycle helmet." b. "Avoid swimming in ponds or lakes." c. "Don't attend fireworks shows." d. "Use a cerumen spoon to clean ears."

ANS: A Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss only if the client has repeated infections. Fireworks displays/shows are loud, but usually brief and only occasional. A cerumen spoon is only used by primary health care providers to remove ear wax from in the ear canal.

A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is most important for this client? a. "Immediately report headache or stiff neck." b. "Keep all follow-up appointments." c. "Take the antibiotics with a full glass of water." d. "Take the antibiotic on an empty stomach."

ANS: A Meningitis is a complication of mastoiditis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

A client is scheduled to have a tumor of the middle ear removed. Which perioperative health teaching is most important for the nurse to include? a. Expecting hearing loss in the affected ear b. Managing postoperative pain c. Maintaining NPO status prior to surgery d. Understanding which medications are allowed the day of surgery

ANS: A Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client.

A client has a hearing aid. What care instructions does the nurse provide the assistive personnel (AP) in the care of this client? (Select all that apply.) a. "Be careful not to drop the hearing aid when handling." b. "Soak the hearing aid in hot water for 20 minutes." c. "Turn the hearing aid off when the client goes to bed." d. "Use a toothpick to clean debris from the device." e. "Wash the device with soap and a small amount of warm water." f. "Avoid using hair or cosmetic products near the hearing aid."

ANS: A, C, D, F All these actions except using water are proper instructions for the nurse to give to the AP.

The nurse is assessing a client's medication profile to determine risk for tinnitus. Which drug classification is most likely to cause this health problem? a. Cephalosporins b. NSAIDs c. Beta-adrenergic blockers d. Osmotic diuretics

ANS: B None of these drug classifications except for NSAIDs pose a risk to clients for tinnitus as a side effect.

A hospitalized client has a new diagnosis of Ménière disease. What would the nurse include in health teaching to reduce symptoms for this disorder? (Select all that apply.) a. "Apply heat to the ear for 20 minutes three times a day." b. "Move the head slowly to prevent worsening of the vertigo." c. "Avoid food additives such as monosodium glutamate (MSG)." d. "Quit smoking to increase blood flow to the inner ear." e. "Avoid caffeinated beverages." f. "Avoid standing on chairs, step stools, or ladders."

ANS: B, C, D, E, F Ménière disease is an excess of endolymphatic fluid that distorts the entire inner-canal system causing vertigo, tinnitus, and unilateral hearing loss. Applying heat or irrigating the ear canal will not alleviate symptoms. Moving the head slowly will prevent worsening of the vertigo. The diet recommendations for Ménière disease include avoiding caffeine and certain food additives. Smoking causes constriction of blood vessels and decreased blood flow to the inner ear. Clients should also avoid standing on high surfaces to prevent vertigo and falls.

A client with Ménière disease is in the hospital when the client has an episode of this disorder. What action by the nurse is appropriate? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client's room. c. Place the client in bed with the upper side rails up. d. Provide a cool, wet cloth for the client's face.

ANS: C Clients with Ménière disease can have vertigo so severe that they can fall. The nurse would assist the client into bed and put the side rails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Ménière disease.

A client has severe tinnitus that has not responded to treatment. What action by the nurse is appropriate? a. Advise the client to take antianxiety medication. b. Educate the client on nerve-cutting procedures. c. Refer the client to online or local support groups. d. Refer the client to a mental health professional.

ANS: C If the client's tinnitus cannot be treated, he or she will need to learn how to cope with it. Referring the client to tinnitus support groups can be helpful. The other options are not warranted.

The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by the nurse is most appropriate? a. "Visit your primary health care provider each month for wax removal." b. "Drink plenty of water and other liquids to prevent hardening of the ear wax." c. "Irrigate each ear once a month to remove wax and prevent was buildup." d. "Put one drop of mineral oil in each ear once a week at bedtime."

ANS: D Mineral oil provides lubrication to soften cerumen so that it flows out of the ears to prevent buildup. It is a safer method than irrigating the ears. If needed, the client would need to go to a primary health care provider for removal of impaction. Drinking water helps prevent hardening of wax but does not necessarily prevent wax buildup.

When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. A. Nits can be removed by a fine-tooth comb. B. Parasites eventually die off without treatment. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest anyplace on the body with hair, including eyelashes and axillae

Answers: A, C, D, E Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed linens and clothing should be washing in hot water to remove lice and eggs; that lice can live on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can infest any body part that has hair. These parasites do not die off without treatment.

An older adult client reports ear pain. Which assessment finding will the nurse report as the priority to the health care provider? Dry, flaky cerumen Pain on movement of the tragus Ringing in the ears Dizziness

Dizziness Dizziness could be the indication of numerous clinical findings; also, the client's risk for falling (or other safety concerns) is raised when dizziness is present. The nurse will report this symptom as the priority to the health care provider.The other concerns can be reported secondary to dizziness.

The nurse notices yellowing at the corners of the sclera in an African-American client. What further assessment will the nurse perform? Gently percuss the liver. Check the oral mucosa. Examine the feet soles. Assess the palms of the hands.

Check the oral mucosa. After assessing an African-American client's sclera for jaundice, the nurse would then check for a yellow tinge to the oral mucous membranes, especially the hard palate.The nurse does not percuss the liver; this will be done by the health care provider. The feet soles and palms of the hands of a client with dark skin may appear yellow, even if jaundice is not present. Therefore, these are not areas of assessment that will be useful in determining if the client has jaundice.

A client with obesity requires frequent dressing changes for an infection on the foot. Which nursing assessment is the priority? Ask the client if he or she is squeamish. Demonstrate how to change the dressing. Determine whether the client can reach the affected area. Provide the necessary dressing materials.

Determine whether the client can reach the affected area. Whether the client can access the affected area is the priority to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home.All other assessments can be performed after determining if the client can reach the affected area.

Koilonychias are found in clients with

iron deficiency, poorly controlled diabetes, and psoriasis.

A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers.

b. Everything between the entry and exit wounds can be damaged. As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.

Precautions for a dressing change for a MRSA pt

don disposable gloves no need to wear a mask or use sterile technique place soiled dressing in a sealed plastic bag

Retinal circulation is evaluated by

fluorescein angiography.

An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What is the appropriate nursing action? Administer an antiemetic. Call the health care provider. Stop irrigation immediately. Use less water to irrigate.

Stop irrigation immediately. If nausea, vomiting, or dizziness develops in the client, the nurse needs to stop the irrigation immediately. The client's nausea may be a sign of vertigo.Antiemetics would not be administered immediately in this case. The client's nausea may be a symptom of vertigo, and further assessment is required first. The health care provider would not be notified before further assessment of the client is done by the nurse. Using less water will not alleviate the client's nausea.

The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication? Oral amoxicillin Oral linezolid Topical mupirocin IV vancomycin

Topical mupirocin Topical mupirocin is an antibiotic that is most likely to be ordered for a client with a mild bacterial skin infection without fever or lymphadenopathy.Recurrent or severe infections may be treated with oral amoxicillin. Clients with methicillin-resistant Staphylococcus aureus infections should be treated with oral linezolid or clindamycin or intravenous vancomycin if the infection is severe.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what is the appropriate nursing action? Test the visual field. Obtain informed consent. Wash the hands. Don sterile gloves.

Wash the hands. Hands must always be washed, and clean gloves donned, before touching the external eye structures to prevent infection.The eye care provider will test the visual field. An informed consent or sterile gloves is not needed for the nurse to examine the client's eye.

A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information? a. "I will shower daily using a super-fatted soap." b. "I can try taking a bath with colloidal oatmeal." c. "I will pat my skin dry instead of rubbing it with a towel." d. "I will be careful to keep my nails filed smoothly."

a. "I will shower daily using a super-fatted soap." The client with pruritus should shower only every other day, although super-fatted soap is an appropriate choice. Colloidal oatmeal baths are very soothing. Patting the skin dry avoids trauma and injury. Keeping nails filed smoothly also prevents injury.

Preexisting conditions that might influence burn recovery are

age, chronic illness (diabetes, cardiac problems, etc.), physical disabilities, disease, medications used routinely, and drug or alcohol abuse.

While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action will the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the patient's oxygen saturation. c. Auscultate the patient's lung fields for adventitious sounds. d. Palpate the patient's bilateral radial and pedal pulses.

b. Use pulse oximetry to assess the patient's oxygen saturation. Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse will assess for systemic oxygenation before continuing with other assessments.

Care plan for MRSA infection

cover w/ clean, dry bandage shower w/ antibacterial soap, clean infected area last avoid bath sponges, use wash cloth only once to prevent launderng

A three-dimensional view of the back of the eye is created by ultrasonic imaging of the retina and optic nerve called

ocular coherence tomography

Best practice for pressure injury wound management includes ongoing assessments that include

pain, using normal saline to clean gently around the wound, ensuring optimal nutrition by involving a registered dietitian nutritionist, using an antimicrobial agent to clean wounds that are anticipated to become infected, and considering the use of adjuvant therapies such as stimulation, negative-pressure wound therapy, ultrasound, hyperbaric oxygen, and topical growth factors. The nurse would not disturb stable eschar.

Signs of pressure ulcer infection are most frequently

stalled wound healing, presence of purulent exudate, increased wound size or depth, fever, elevated WBC count, and increased pain. Cultures are not usually obtained.

Age-related differences that can increase the risk of burns and complications of burns include

thinner skin, slower healing, decreased mobility, increased risk of infection that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses

When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? "One of my eyes is green and the other is blue." "My eyes are red and itchy due to allergies." "My vision has been getting worse gradually." "Something hit my eye while I was cutting grass."

"Something hit my eye while I was cutting grass." The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist.All other reports will be communicated to the ophthalmologist, but do not require immediate intervention. Heterochromia is an ocular condition, usually genetically inherited, that causes the iris to vary in color. This is not an emergency. Itching and redness can be caused by allergies, irritation, or ocular drug effects but do not require immediate attention. Gradual vision loss could be caused by uncontrolled hypertension and diabetes, or other eye changes, but this does not require immediate care by an ophthalmologist.

A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon. b. Stage 2: may have visible adipose tissue and slough. c. Stage 3: may have a pink or red wound bed. d. Stage 4: wound bed is obscured with eschar or slough.

ANS: A A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An unstageable wound is obscured by eschar or slough making assessment impossible.

An older adult in the family practice clinic reports a decrease in hearing in one ear for over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

ANS: A All options are possible actions for the client with hearing loss. The first action the nurse would take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications would be assessed for ototoxicity. Further auditory testing may be needed for this patient.

A client had a myringotomy. What would the nurse include as part of discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.

ANS: A The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action would the nurse take? a. Request a prescription for permethrin. b. Administer an antihistamine. c. Assess the client's airway. d. Apply gloves to minimize friction.

ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin. The nurse would contact the primary care provider to request a prescription for one of the medications. Secondary interventions may include medication to decrease the itching. The client's airway is not at risk with this skin disorder. Applying gloves will help prevent transmission.

A client has a foreign body in one eye. What action by the nurse is appropriate for the client's care? a. Administering ordered antibiotics b. Assessing the patient's visual acuity c. Obtaining consent for enucleation d. Removing the object immediately

ANS: A To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client's airway. b. Irrigate the client's skin. c. Brush any visible dust off the skin. d. Call poison control for guidance

ANS: A With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called.

The nurse is assessing a client admitted to the emergency department with possible retinal detachment. What assessment findings would the nurse expect? (Select all that apply.) a. Presence of bright light flashes b. Decreased visual field in affected eye c. Feeling like a curtain is over one eye d. Gradual changes in visual acuity e. Painful throbbing in the affected eye

ANS: A, B, C Changes that occur in clients experiencing retinal detachment are usually sudden and painless. Typical changes that occur include bright light flashes, sudden decrease in visual filed, and a feeling like a curtain is over all or part of the affected eye.

The nurse is teaching a client about care after surgery to repair a retinal detachment. What health teaching would the nurse include? (Select all that apply.) a. "Report sudden pain in the surgical eye." b. "Report if the surgical eye remains dilated." c. "Avoid close vision activities in the first week." d. "Avoid activities that increase intraocular pressure." e. "Report sudden reduced visual acuity."

ANS: A, B, C, D, E All of these instructions are important for the client who has a retinal detachment repair.

The nurse is teaching a client about postoperative care after a LASIK procedure. Which common complications/adverse effects could occur either immediately or later after this type of surgery? (Select all that apply.) a. Halos around lights b. Blurred vision c. Blindness d. Infection e. Dry eyes

ANS: A, B, D, E All of these common problems can occur after LASIK surgery except for blindness. Some decrease in visual acuity can occur, however.

The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

ANS: A, B, D, E Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

A client has multiple lesions all over the body and a family history of skin cancer. The nurse teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient's teaching? (Select all that apply.) a. "Look for asymmetry of shape and irregular borders." b. "Assess for color variation within each lesion." c. "Examine the distribution of lesions over a section of the body." d. "Monitor for edema or swelling of tissues." e. "Focus your assessment on skin areas that itch." f. "Report any lesions that change over time in any way."

ANS: A, B, F Patients will be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

A nurse is working with a client who has a painful rash consisting of grouped weeping and crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all that apply.) a. Instruct the client to report lesions near the eyes. b. Have the client take long, hot baths to soak the lesions. c. Show the client how to make a baking soda compress. d. Advise the client to avoid exposure to UV light rays. e. Demonstrate proper use of antifungal medications. f. Review appropriate hygiene measures.

ANS: A, C This client has herpes zoster (shingles). Eye infection is possible, so the client should be taught to report any lesions erupting near the eyes. Comfort measures can include compresses, calamine lotions, and baking soda. Long hot baths are not recommended. Avoiding UV lighting is important for herpes simplex. Herpes zoster is a viral disorder, so antifungal medications are not used. Hygiene is not an issue causing an outbreak.

A nurse plans care for a client who has a wound that is not healing. Which focused assessments will the nurse complete to develop the patient's plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results f. Weight

ANS: A, C, D, E Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status will include a high-protein, high-calorie diet. To determine the patient's nutritional status, the nurse will assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and body mass. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.

A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which nonpharmacologic comfort measures would the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with colloidal oatmeal e. Back rub with baby oil

ANS: A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse would implement cool, moist compresses and tepid baths with additives such as colloidal oatmeal. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

A nurse plans care for a client who is immobile. Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the client's heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they would be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients would be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? a. Requests a referral to a registered dietitian nutritionist. b. Raises the head of the bed no more than 45 degrees. c. Performs perineal cleansing every 2 hours. d. Assesses the client's entire skin surface daily.

ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. The nurse needs to keep the head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN consultation, frequent perineal cleaning, and assessing the client's entire skin surface are all appropriate actions.

A client had a retinal detachment and has undergone surgical correction. What discharge health teaching is most important for the nurse to include? a. "Avoid reading, writing, or close work such as sewing." b. "Report immediate loss of vision of pain in the affected eye." c. "Keep the follow-up appointment with the ophthalmologist." d. "Remove your eye patch every hour for eyedrops."

ANS: B After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because these activities cause rapid eye movements. However, more importantly is the need for the client or family to report loss of vision or pain in the surgical eye. Keeping a postoperative appointment is important for any surgical patient. The eye patch is not removed for eyedrops after retinal detachment repair.

A nurse assesses a client who has psoriasis. Which action would the nurse take first? a. Don gloves and an isolation gown. b. Shake the client's hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse would first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy would be completed after establishing a report with the client.

The nurse is teaching a client about factors that can cause external otitis. Which of these factors would the nurse emphasize as the highest risk? a. Excess cerumen b. Swimming c. Sinus congestion d. Meniere disease

ANS: B External otitis is often called "swimmer's ear" because it is most often caused by swimming in lakes, ponds, and untreated pools.

A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? a. "Dermabrasion or chemical peels can be done in the office." b. "I may need lymph node resection during Mohs surgery." c. "This needs only a small excision with local anesthetic." d. "After surgery I will need 8 weeks of radiation therapy."

ANS: B Melanoma is usually treated with Mohs micrographic surgery, in which tissue is sectioned horizontally in layers and examined histologically, layer by layer, to assess for cancer cells. Dermabrasion and chemical peels can be used on actinic keratoses. Local anesthetic for small excisions is generally used on basal or squamous cell carcinomas. Radiation is usually not used with melanoma.

A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel

ANS: B Pale conjunctivae signify anemia. The nurse will assess the client's hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client's potential anemia.

A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection? a. WBC 9200 mm/L3 (9.2 × 109) b. Boggy feel to granulation tissue c. Increased size after debridement d. Requesting pain medication

ANS: B Wound infection may or may not occur in the presence of signs of systemic infection, but a change in the appearance, texture, color, drainage, or size of a wound (except after debridement) is indicative of possible infection. The nurse would assess the client with boggy granulation tissue further. The WBC is normal. After debridement, the wound may look larger. If the client needs a sudden increase in the amount or frequency of pain medication that would be another indicator, but there is no evidence this client has more pain than usual.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you recently used a public shower?" d. "Have you been out of the country recently?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

ANS: B, E, F Outbreaks of psoriasis can be induced by stress, environmental triggers, certain medications, skin injuries, infections, smoking, alcohol use, and obesity. Psoriatic lesions are not triggered by chocolate, public showers, or international travel

A client has external otitis. About what comfort measure would the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier

ANS: C A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not appropriate.

The nurse is teaching a client about cataract surgery. Which statement would the nurse include as part of preoperative preparation? a. "You will receive general anesthesia for the surgical procedure." b. "You will be in the hospital for only 1 to 2 days if everything goes as expected." c. "You will need to put several types of eyedrops in your eyes before and after surgery." d. "You will be on bedrest for about a week after the surgical procedure."

ANS: C Cataract surgery is done as an ambulatory care procedure and the client is not hospitalized, does not receive general anesthesia, and does not need to be on bedrest postoperatively.

A nurse is teaching a client and family about self-care at home for the client's wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? a. "I will keep dry bandages on the wound and change them when drainage appears." b. "I will shower instead of taking a bath in the bathtub each day." c. "If the dressing is dry, I can sit or sleep anywhere in the house." d. "I will clean exposed household surfaces with a bleach and water mixture."

ANS: C The client should not sit on upholstered furniture or sleep in the same bed as another person until the infection has cleared. The other statements show good understanding.

A client's intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Teach about drugs for glaucoma. d. Refer the patient to local Braille classes.

ANS: C This increased IOP indicates glaucoma. The nurse's main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate? a. "The wound edges have been approximated and stitched together." b. "The wound was stapled together after an infection was cleared up." c. "The wound is an open cavity that will fill in with granulation tissue." d. "The wound was contaminated by debris and can't be closed at all."

ANS: C Wounds healing by second intention are deeper wounds that leave open cavities. These wounds heal as connective tissue fills in the dead space. A wound that has its edges brought together (approximated) and sutured or stapled together is said to be healing by first intention. A wound that was left open while an infection healed and then is closed is an example of healing by third intention. A wound that cannot be closed at all would be left to heal by second intention.

A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection would the nurse refer to an audiologist as the priority? a. Client with an hour car commutes on the freeway each day. b. Client who rides a motorcycle to work 20 minutes each way. c. Client who sat in the back row at a rock concert recently. d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day.

ANS: D A chainsaw becomes dangerous to hearing after several hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic and motorcycle noise is safe unless for a very long time. Although a client was at a rock concert, he or she was in the back row and had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.

A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

ANS: D A client with an ulcer on the foot would be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse emphasize as possibly indicating beginning cataract formation? a. Diplopia b. Cloudy pupil c. Loss of peripheral vision d. Blurred vision

ANS: D A cloudy pupil is a sign of late cataracts and loss of peripheral vision is more common in clients who have glaucoma. Diplopia occurs with a number of neurologic diseases. Blurred vision is the earliest sign that the lens of the eye is undergoing changes.

A client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate? a. "Take monthly photographs of it so you can document any changes." b. "Wash daily with warm water and gentle soap to prevent infection." c. "Keep the lesion covered with a bandage and triple antibiotic ointment." d. "Please make an appointment to be seen here as soon as possible."

ANS: D A lesion demonstrating a change in characteristics, such as oozing, crusting, bleeding, or scaling, is suspicious for skin cancer. The nurse would instruct the client to come in for evaluation. Monthly photographs are a good way to document skin changes, but the client needs an assessment for skin cancer. The lesion can be washed and covered with a bandage and ointment, but again, the client needs an evaluation for skin cancer.

The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development? a. Heart disease b. Glaucoma c. Diabetes mellitus d. Advanced age

ANS: D Advanced age is the major risk factor for developing cataracts because the lens loses water and lens fibers become more compact.

An older adult client with a long history of congestive heart failure is being treated for a pressure injury over the coccyx that is 4 cm wide and 5 cm long, with eschar present. Which technique does the nurse anticipate will be used to remove the necrotic tissue? Surgical removal Biologic dressing Continuous dry gauze dressing Dressings along with a topical enzyme preparation

ANS: D Although surgical removal of necrotic tissue may be indicated for some clients, those who are older but too ill or debilitated for surgery will require a nonsurgical approach to ulcer débridement. A biologic dressing is appropriate once the eschar has been removed. A continuous dry gauze dressing is not appropriate for débridement. Topical enzyme preparations help soften and remove eschar.

A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question will the nurse ask first? a. "Are you using lotion on your skin?" b. "Do you have a family history of this?" c. "Do your arms itch?" d. "What medications are you taking?"

ANS: D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

A client who has had cold symptoms for a week visits the local urgent care center with report of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings would the nurse expect? a. High fever b. Nausea and vomiting c. Elevated blood pressure d. Purulent ear drainage

ANS: D The client presents with symptoms that indicate possible serous otitis or otitis media. In either case, the client would not have a high fever or blood pressure. Nausea and vomiting are not common with either diagnosis, but purulent ear drainage is likely to occur if the tympanic eardrum perforates. The client's decreased hearing could indicate that perforation already occurred.

A client is taking timolol eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? a. Ask the client about excessive salivation. b. Take the client's blood pressure and temperature. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the primary health care provider.

ANS: D The nurse would hold the eyedrops and notify the primary health care provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Taking the blood pressure and temperature are not necessary. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? a. Wet-to-damp saline moistened gauze b. None, the wound is left open to the air c. A transparent film d. Multi-fiber superabsorbent dressing

ANS: D This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of necrotic tissue. A draining wound would not be left open. A transparent film is a good choice for a noninfected stage 2 pressure injury.

A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Presence of toenail fungus d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

ANS: D, F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the Skin Cancer Foundation's hallmark signs for cancer according to the ABCDE method. Other signs and symptoms, while not normal, are not cause for concern.

Which client does the nurse identify that is at high risk for developing hearing problems? (Select all that apply.) Airline mechanic Client with Down syndrome Drummer in a rock band Teenager listening to music using ear buds Telephone operator

Airline mechanic Client with Down syndrome Drummer in a rock band Teenager listening to music using ear buds Clients who are at high risk for hearing problems include an airline mechanic who is exposed to excessive noise, a client with Down syndrome, (a genetic condition associated with frequent hearing problems), a drummer in a rock band due to exposure to loud noise, and a teenager listening to music using ear buds. Ear buds are known risk factors for increasing potential hearing loss among people who use them on a regular basis with elevated noise levels.A telephone operator is not at risk for hearing problems simply because he or she may wear headphones or audio equipment.

Which supplement will the nurse recommend to a client who wishes to enhance eye health? Lutein Vitamin D Magnesium Saw palmetto

Answer: A Rationale: Lutein, zeaxanthin, and beta carotene have been shown to enhance eye health. Vitamin D, Magnesium, and saw palmetto are not associated with enhancement of eye health.

What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma? Seeing "shooting stars" Decrease in central vision Gradual loss of visual fields Abrupt onset of excruciating pain

Answer: C Rationale: Glaucoma is a condition in which onset is gradual and slow; therefore, the nurse will anticipate this type of assessment data collected from a client with a new diagnosis. Glaucoma is not characterized by seeing "shooting stars", experiencing a decrease in central vision, nor an abrupt onset of excruciating pain.

Which client statement regarding treatment of a skin infection requires intervention by the nurse? A. "I am not going to share my clothes with anyone else." B. "Because I am over 60, I am going to get the shingles vaccine." C. "It is important to keep my skin very moist, so I will use lotion." D. "If I get a fever or chills, I will contact my primary health care provider."

Answer: C Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin moist. The skin actually needs to be kept clean and dry, and moisture can provide an environment for bacteria to continue to thrive. The nurse does not need to intervene when the client understands that clothing should not be shared, that the shingles vaccine is indicated for individuals over 50, and that fever and chills should be reported to the primary health care provider.

Which patient does the nurse identify at highest risk for development of dry age-related macular degeneration (AMD)? 55-year old client who recently began wearing glasses 59-year old client who has controlled hypertension 62-year old client with hypothyroidism 65-year old client with diabetes

Answer: D Rationale: Individuals over the age of 60 and that have hypertension, diabetes, or high cholesterol are at the highest risk for development of dry age-related macular degeneration (AMD). The client who is 55 and recently began wearing glasses is at lower risk than the other three patients, since he or she is not over 60, and wearing glasses is not associated with AMD. The 59-year old client with controlled hypertension is at lower risk due to age, and since the hypertensive condition is treated and controlled. The 62-year-old individual is at lower risk, as hypothyroidism is not associated with AMD. The 65-year old individual is at highest risk having two risk factors: age, and the condition of diabetes.

What teaching will the nurse provide to a client who has just been fitted for new hearing aids? Leave the hearing aid on, even if not wearing it Immerse the ear mold in alcohol to fully clean it Store the hearing aid in a warm, humid bathroom when not in use Avoid using hair spray, makeup, and personal care products around the device

Answer: D Rationale: The nurse will teach the client who has just been fitted for new hearing aids to avoid using hair spray, makeup, and personal care products around the device. These can compromise the integrity of the hearing aid. The hearing aid should be turned off when not in use as this preserves the battery. The ear mold should be cleaned with soap and water, and never immersed. The hearing aid should be kept in a clean area free from temperature extremes when not in use.

When teaching a community group about burn prevention, which education will the nurse include? A. "Have a smoke detector in one central spot in the home." B. "If you use home oxygen, turn it down when you are smoking." C. "Set your water heater temperature below 160 degrees F. (71 C.)." D. "Plan several ways of escape from the home in case the primary exit is blocked."

Answer: D Rationale: The nurse will teach that multiple routes of escape should be planned in case the primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a central location. The client should never smoke around home oxygen. The water heater temperature should be set below 120°F (49°C.) or burns may occur.

Which communication method is appropriate when the nurse is interacting with a client who is deaf? Use pictures and writing Speak with enunciated words Ask client to read the nurse's lips Dialogue specifically with the client's caregivers

Answers: A Rationale: The nurse will use pictures and writing to communicate with a client who is deaf. It is inappropriate to enunciate words, as the client cannot hear. Not all clients who are deaf can read lips. Dialoguing specifically with the client's caregivers excludes the client from his or her own care.

Which symptoms will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply. Pain in the affected eye Pus in the affected eye Decreased visual acuity Temperature of 99.0 degrees F Pupil that constricts in response to light

Answers: A, B, C Rationale: Pain, pus, or decreased visual acuity in an eye that recently underwent correction for a retinal detachment must be immediately reported to the eye care provider, as they can indicate a post-surgical complication. A temperature 99 degrees F is not cause for alarm, unless the temperature elevates to 100.6 degrees F or above. A pupil that constricts in response to light is a normal finding.

Which client statement regarding a new diagnosis of tinnitus requires nursing teaching? Select all that apply. "I am so glad this condition will go away permanently." "It is important that I do not drive when I have tinnitus." "Watching my diet will make a difference in my condition." "Surgery is the only treatment that is available for tinnitus." "I have found a couple of support groups that I like to attend."

Answers: A, C, D Rationale: Tinnitus is a condition that ranges from mild ringing to severe roaring in the ear. It is a problem that comes and goes, although does not go away permanently. Research does not correlate a specific diet to resolution of tinnitus. Treatment is geared towards symptom management and masking the sound. Surgery is a last resort treatment method; lifestyle modifications and non-surgical interventions are always used first. Therefore, these statements require further nursing teaching. Recognizing that it is unsafe to drive when experiencing tinnitus, and attending support groups, are healthy statements that do not require nursing intervention.

Which assessment data does the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye that started 30 minutes prior? Select all that apply. Pain Fever Tearing Photophobia Blurred vision

Answers: A, C, D, E Rationale: The nurse will anticipate that a client who has a foreign body in the eye will report some level of pain or discomfort, tearing (as the foreign body irritates the tissue within the eye), photophobia (as it may be difficult to see if there is the presence of a foreign body and the automatic response is to close the eye), and blurred vision (if the foreign body obstructs the line of sight). Fever is not associated with a foreign body that has been in the eye for such a short amount of time; this symptom may be present if infection arose from a foreign body that had been present for a longer period of time.

What teaching will the nurse provide to the client who just had a skin biopsy taken and sutures placed to close the wound? Select all that apply. A. Use antibiotic ointment as prescribed B. Return for suture removal in 2-3 days C. Report redness to the healthcare provider D. Keep dressing moist so skin does not dry out E. Use tap water or saline to remove any crusting

Answers: A, C, E Rationale: Following a biopsy, the nurse will teach the client to care for the wound to reduce the risk for infection. Teaching includes using antibiotic ointment as prescribed, returning for suture removal in 7-10 days, reporting redness or excessive drainage to the healthcare provider, keeping the dressing dry, and using tap water or saline to remove dried blood or crusting.

Which client statement affirms that nurse teaching about instillation of multiple different eye drops has been effective? Select all that apply. "It will be very easy for me to instill all of the drops at one time." "A schedule will help me remember when to instill the eyedrops." "If I have trouble instilling the drops, there are devices that can be helpful." "I can label the eye drops by color to help me easily distinguish which one is which." "I will not touch the droppers to my eyes as this can cause contamination and infection."

Answers: B, C, D, E Rationale: Teaching has been effective when a client can verbalize the need to create a schedule to remember when to instill eyedrops, to use a device if self-instillation is not possible, to label eyedrops by color to distinguish them, and to refrain from touching the dropper to the eye to reduce the chance of infection and contamination. Drops cannot be instilled all at one time, as each prescription will have its own dosing schedule. Even when taking drops around the same time, the client must be taught to pause between instillation of different drops.

What teaching will the nurse provide to a client who continues to experience more frequent episodes associated with Ménière disease? Select all that apply. Reducing activity can reduce frequency of episodes. Episodes will eventually decrease in severity and number. Reducing sodium, caffeine, and alcohol intake can be beneficial. The only treatment that is effective is to undergo labyrinthectomy. When moving from sitting to standing, be cautious and take your time.

Answers: C, E Rationale: The nurse will teach that (1) increase in activity, especially activities that strengthen balance, can be helpful; (2) episodes are not predictable in terms of severity and frequency; (3) reduction of high salt intake, caffeine, monosodium glutamate (MSG), alcohol, nicotine, stress, and allergens can be beneficial; (4) labyrinthectomy is one of several surgical treatments that can be considered; and (5) it is important to be cautious when moving during an attack, as vertigo can result in falls.

When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? Select all that apply. Hair in the ear thins and fall outs Hearing acuity changes in all older adults Cerumen dries and becomes impacted more easily The ability to hear low-frequency pitches diminishes first Sounds such as f, s, sh, and pa may be more difficult to discern

Answers: C, E Rationale: The nurse will teach the group of older adults that (1) hair in the ear thickens and becomes more coarse; (2) hearing acuity changes in some - but not all - older adults; (3) cerumen dries and becomes more easily impacted; (4) the ability to hear high-frequency pitches diminishes first; and (5) sounds such as f, s, sh, and pa become more difficult to discern as people age.

An older adult client comes in for a routine visit. During the assessment he appears frustrated and says, "Speak up and quit mumbling!" What is the appropriate nursing response? Apologize and speak louder and clearer. Ask if the client has hearing loss. Shout to ensure that the client can hear. Suggests moving to a soundproof examination room.

Apologize and speak louder and clearer. The nurse would repeat and speak more clearly first and then determine whether further assessment is needed.It would not be assumed that the client has a hearing loss; this suggestion may frustrate the client, especially if he is in denial. Shouting is not recommended because it can make understanding more difficult; this is also considered rude and nontherapeutic. Soundproof rooms are used for hearing tests, not for routine assessments.

Which characteristic of a skin lesion will the nurse report to the health care provider? (Select all that apply.) 1-mm ecchymotic area on the upper extremity Asymmetry Dark red color Round and raised appearance Irregular border Size increase from last month

Asymmetry Irregular border Size increase from last month A lesion with one or more of the ABCDE (asymmetry, border irregularity, color variation, diameter, evolving) features should be evaluated by a dermatologist or a surgeon. Therefore, the nurse will report these findings to the health care provider.Ecchymosis is a bruise and is not necessarily problematic; it is common after minor trauma. A dark red color or a round and raised appearance is not necessarily problematic.

Which assessment data regarding a lesion found on a 39-year old client who uses a tanning bed requires nursing intervention? Select all that apply. Symmetrical and light pink Brownish-purple with irregular borders Changed in shape since last appointment 8 mm wide and described as itching often Regular border with fixed size and elevation

Brownish-purple with irregular borders Changed in shape since last appointment 8 mm wide and described as itching often Using the Skin Cancer Foundation's ABCDE approach to assessment of skin lesions, the nurse must intervene if a skin lesion has any of the following characteristics: Asymmetry of shape Border irregularity Color variation within one lesion Diameter greater than ¼ of an inch or 6 mm Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

A client has an odorous, purulent wound, and reports feeling embarrassed. Which nursing intervention is appropriate? Change the dressing frequently. Encourage a diet high in protein. Suggest whirlpool therapy. Place room deodorizers in the room.

Change the dressing frequently. The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the appropriate nursing intervention.A diet high in protein does not address the client's feelings of embarrassment. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first? a. Client with intraocular pressure reading of 24 mm Hg b. Client with a tearing, reddened eye with exudate c. Client whose red reflex is absent on ophthalmologic examination d. Client who has had cataract surgery and has worsening vision

Client who has had cataract surgery and has worsening vision After cataract surgery, worsening vision indicates a postoperative infection or other complication. The nurse would see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN? Client with a sutured facial tear after falling off a bike. Client who needs grafting of a second-degree burn on the right leg. Client who needs discharge teaching after receiving steroids for Stevens-Johnson syndrome. Client with a stage I pressure injury who requires turning every 2 hours

Client with a sutured facial tear after falling off a bike. An LPN/LVN is an appropriate choice to care for an adult client with a facial suture. This nurse would be familiar with wound monitoring for potentially contaminated wounds and would recognize signs of infection. Conducting discharge teaching is a more complex nursing action that requires RN-level education and scope of practice. The client with stage I pressure injuries who needs to be turned every 2 hours could be cared for by a nursing assistant.

The nurse is caring for four clients with eye concerns. Which client, who has a family history of an eye disorder, does the nurse identify at risk for increased intraocular pressure (IOP)? Client with family history of anisocoria Client with family history of presbyopia Client with family history of diabetic retinopathy Client with family history of glaucoma

Client with family history of glaucoma Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year.Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population. This condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near objects. Increased IOP is not a factor. Diabetic retinopathy is microvascular damage caused by uncontrolled diabetes, not by increased IOP.

The nurse has just received change-of-shift report about these clients. Which client will the oncoming nurse assess first? Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic. Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache Client who has acute otitis media and is reporting drainage from the affected ear.

Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache The client with an elevated temperature and headache with labyrinthitis must be assessed first. These findings may indicate that the client has developed meningitis requiring immediate intervention.Severe nausea is an expected finding with Ménière's disease. Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma. Drainage from the affected ear can be an expected finding with otitis media.

_______________ Precautions need to be used when assessing drainage from a client's ear canal.

Contact

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

Corneal staining Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

A client with a large, irregular shaped mole on her upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatological health care provider. B. Ask if there are any other lesions that bother her. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.

Correct Answer: C Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as the priority; there may be other skin lesions that need attention. Once this is done, the nurse can then query whether other lesions are bothersome, teach about avoidance of sun and tanning beds, and refer the client to a dermatologic health care provider.

Which systemic disorder may affect vision and require yearly eye examination by an ophthalmologist? (Select all that apply.) Anemia Diabetes mellitus Hepatitis Hypertension Multiple sclerosis (MS)

Diabetes mellitus Hypertension Multiple sclerosis (MS) Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity. Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

A client with a foot ulcer says, "I feel helpless." What is the appropriate nursing response? (Select all that apply.) Encourage participation in care of the wound. Suggests inviting visitors to come. State,"I know how you feel." Assure that everything will be OK. Ask what coping strategies have worked in the past.

Encourage participation in care of the wound. Ask what coping strategies have worked in the past. The nurse's appropriate responses are to encourage client participation in wound care, and to ask how the client has coped with feelings like this in the past. Participation in wound care gives the client a sense of autonomy. Learning what coping strategies worked in the past alerts the nurse to whether the client copes with healthy or unhealthy coping mechanisms. Encouraging visitors is not the right suggestion for this client at this time; he or she needs to participate in self-care first. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing and nontherapeutic. Assuring the client that everything will be all right not only fails to address the underlying issue—but it also minimizes the client's feelings, and may give false hope.

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drug does the nurse identify as a possible cause of the client's hearing change? (Select all that apply.) Acetaminophen Atenolol Erythromycin Ibuprofen Insulin Furosemide

Erythromycin Ibuprofen Furosemide The nurse identifies erythromycin, ibuprofen, and furosemide as medications known to increase the risk for ototoxicity and hearing problems.Acetaminophen, beta blockers, and insulin are not known ototoxic drugs.

A client with a stage 1 pressure injury has slipped to the bottom of the bed. What action does the nurse take first? Move the client gently upward. Get help to lift the client. Assess for broken skin areas. Pad the bony prominences.

Get help to lift the client. The first action by the nurse would be to get help, and then and gently lift the client with a sheet.Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences are not the priorities of care, and can be accomplished after the client is positioned appropriately.

A client is admitted to the emergency department with metal shards in the right eye. Which diagnostic test ordered by the health care provider does the nurse question? Magnetic resonance imaging (MRI) Ophthalmoscopy Radioisotope scanning Snellen chart

Magnetic resonance imaging (MRI) Because the client has metal in the eye, MRI is an absolute contraindication.Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

The nurse is caring for a client who is admitted with mastoiditis. Which nursing action is appropriate? Prepare to administer IV antibiotics Teach about Swim-Ear to dry the ears better. Don gloves to examine the pinna. Perform a baseline hearing assessment.

Prepare to administer IV antibiotics The appropriate nursing action when a client is admitted for mastoiditis is to prepare to administer IV medication. Mastoiditis can progress to a brain abscess, meningitis, or death if not appropriately managed. Teaching about Swim-Ear, donning gloves to examine the pinna, and performing a baseline hearing assessment are not parts of care associated with mastoiditis. Interventions are focused on halting the infection before it spreads to other structures.

An older adult client who is bedridden has a documented history of protein deficiency. For which condition will the nurse monitor and attempt to prevent? Melanoma Decreased wound healing Pressure injury development Bed bugs

Pressure injury development This client is at risk for developing pressure injuries related to protein deficiency if he or she remains bedridden.Melanoma and bed bugs have no correlation with this client's protein deficiency. The client does not have a wound that needs monitoring.

The nurse observes multiple small pits in all of a client's fingernails. The nurse suspects that the client may have which condition? Cystic fibrosis Iron deficiency anemia Prolonged febrile illness Psoriasis

Psoriasis Pitting of the fingernails may be seen in clients with psoriasis and alopecia areata. It can involve several or all of the fingernails and also be associated with plate thickening and onycholysis. Late clubbing of the fingernails is a sign of cystic fibrosis. Spoon nails (koilonychias) are a sign of iron deficiency anemia. Beau grooves are a sign of prolonged febrile illness.