Exam 5 Study Set

Your patient is being treated for open-angle glaucoma. What assessment finding is NOT typically present with this type of glaucoma? A. Tunnel vision B. Cloudy vision C. Optic disc cupping D. High intraocular pressure

B. Cloudy vision Cloudy vision is associated with cataracts, while tunnel vision is associated with glaucoma due to the loss of peripheral vision.

A patient with glaucoma is ordered eye medication for the right eye in the form of an ointment and eye drop. The nurse will administer which type of medication first? A. Ointment and then the eye drops B. Eye drops and then the ointment

B. Eye drops and then the ointment The nurse will administer eye drops FIRST and then the ointment.

A patient in the oliguric phase after an acute kidney injury has had a 250-mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours? ____________

950 mL The general rule for calculating fluid restrictions is to add all fluid losses for the previous 24 hours, plus 600 mL for insensible losses: (250 + 100 + 600 = 950 mL).

Your patient has a history of angle-closure glaucoma. What type of medications should this patient avoid? A. Anticholinergics B. Cholinergics C. Beta blockers D. Alpha-agonists

A. Anticholinergics Angle-closure glaucoma occurs when the drainage angle of the eye becomes too narrow or closed to allow aqueous humor to drain out of the eye. This fluid stays in the eye and increases intraocular pressure, which can damage the optic nerve. Dilation of the pupils can push the iris forward and block off the drainage angle. Therefore, this patient should avoid anticholinergics. Remember anticholinergics cause dilation of the pupils...therefore, patients with angle-closure glaucoma should avoid these medications unless otherwise approved by their doctor.

A patient with open-angle glaucoma has developed thicker and longer eyelashes and reports a darkening of their eye color. You assess the patient's medication list. What glaucoma medication on the patient's medication list can cause this side effect? A. Bimatoprost B. Pilocarpine C. Acetazolamide D: Timolol

A. Bimatoprost Bimatoprost is a prostaglandin analog and can cause these signs and symptoms.

A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of uncontrolled hypertension and coronary artery disease. You're assessing the new medication orders received for this patient. Which medication ordered by the physician will help treat the patient's hypertension along with providing a protective mechanism to the kidneys? A. Lisinopril B. Metoprolol C. Amlodipine D. Verapamil

A. Lisinopril There are two types of drugs that can be used to treat hypertension and protect the kidneys in patients with CKD. These drugs include angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs). The only drug listed here that is correct is Lisinopril. This drug is known as an ACE inhibitor. Metoprolol is a BETA BLOCKER. Amlodipine and Verapamil are calcium channel blockers.

A patient with stage 4 chronic kidney disease asks what type of diet they should follow. You explain the patient should follow a: A. Low protein, low sodium, low potassium, low phosphate diet B. High protein, low sodium, low potassium, high phosphate diet C. Low protein, high sodium, high potassium, high phosphate diet D. Low protein, low sodium, low potassium, high phosphate diet

A. Low protein, low sodium, low potassium, low phosphate diet The patient should follow this type of diet because protein breaks down into urea (remember patient will have increased urea levels), low sodium to prevent fluid excess, low potassium to prevent hyperkalemia (remember glomerulus isn't filtering out potassium/phosphate as it should), and low phosphate to prevent hyperphosphatemia.

You are providing education to a patient with CKD about calcium acetate. Which statement by the patient demonstrates they understood your teaching about this medication? Select-all-that-apply: A. "This medication will help keep my calcium level normal." B. "I will take this medication with meals or immediately after." C. "It is important I consume high amounts of oatmeal, poultry, fish, and dairy products while taking this medication." D. "This medication will help prevent my phosphate level from increasing."

B. "I will take this medication with meals or immediately after." D. "This medication will help prevent my phosphate level from increasing." Calcium acetate (also known as PhosLo) is a phosphate binder, which will help keep the patient's phosphate level from becoming too high. It helps excrete the phosphate taken in the food by excreting it out of the stool. Therefore, it should be taken with meals or immediately after. Option C is wrong because the patient should AVOID these types of foods high in phosphate.

An elderly patient who lives in an adult assisted-living agency mentions that he is experiencing hearing and vision changes. During your assessment, you would associate this type of sensory deprivation with A. Stable affect. B. Altered perception. C. Improved task completion. D. Increased need for social interaction.

B. Altered perception. The patient is experiencing a new environment with various new sounds and surroundings that are unfamiliar to the patient.

A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for? A. Hypercalcemia B. Anemia C. Blood clots D. Hyperkalemia

B. Anemia EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.

While assessing morning labs on your patient with CKD. You note the patient's phosphate level is 6.2 mg/dL. As the nurse, you expect to find the calcium level to be? A. Elevated B. Low C. Normal D. Same as the phosphate level

B. Low A normal phosphate level is 2.7-4.5 mg/dL. This patient is experiencing HYPERphosphatemia. When hyperphosphatemia presents the calcium level DECREASES because phosphate and calcium bind to each. When there is too much phosphate in the blood it takes too much calcium with it and it decreases the calcium in the blood. Therefore, the nurse would expect to find the calcium level decreased.

The patient is ordered to take Timolol for the treatment of glaucoma. Before administration the nurse will educate the patient about this new medication. Which of the following information is the MOST pertinent the nurse to include? A. Measuring the heart rate because this medication can cause tachycardia B. Performing punctal occlusion after instilling the eye drops C. Avoid taking this medication with any other glaucoma medications. D. Always administer this medication 1 minute before another type of glaucoma medication.

B. Performing punctal occlusion after instilling the eye drops Timolol is a beta blocker, and it is administered via eye drops for the treatment of glaucoma. It is very important the patient perform punctal occlusion after instilling the eye drop to prevent systemic effects of the medication. The medication needs to stay in the eye rather than enter the blood stream. Punctal occlusion is where the tear duct is blocked with the index finger for about 2-3 minutes. This will prevent the medication from draining down into the nasolacrimal duct.

A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is A. Administering a sleep aid. B. Synchronizing the medication, treatment, and vital signs schedule. C. Encouraging the patient to exercise immediately before sleep. D. Discussing with the patient the benefits of beginning a long-term nighttime medication regimen.

B. Synchronizing the medication, treatment, and vital signs schedule. Sleep pattern disturbance within the hospital setting often occurs due to multiple awakenings throughout the night such as medication, treatment, and vital sign schedules. It is important to minimize the amount of interruptions that can occur for the patient throughout the night.

A patient is scheduled to take Brimonidine and Latanoprost eye drops for management of glaucoma at 1000. What correct action below will the nurse take when administering these eye drops? A. The nurse assists the patient with using the index finger to gently place pressure at the side of the nose bridge for about 30 seconds after administering each eye drop medication. B. The nurse waits at least 3-5 minutes before administering the second eye drop medication. C. The nurse administers each eye drop directly on the eye via the cornea. D. The nurse encourages the patient to blink after each eye drop administration.

B. The nurse waits at least 3-5 minutes before administering the second eye drop medication. This is the only correct action by the nurse. The nurse should wait at least 3-5 minutes before administering the second medication. This is so that the first medication can be used by the eye and not washed out by the second medication.

Your patient is ordered to take Acetazolamide for treatment of glaucoma. What in the patient's history would require you to hold the medication and obtain an order clarification from the physician? A. The patient has open-angle glaucoma. B. The patient is allergic to sulfonamides. C. The patient reports tunnel vision. D. The patient's IOP is 25 mmHg.

B. The patient is allergic to sulfonamides. Patients who have a sulfonamide allergy should NOT take carbonic anhydrase inhibitors (hence Acetazolamide).

You're providing care to a patient who just had glaucoma surgery. The patient is alert and oriented. Vital signs are: heart rate 82 bpm, blood pressure 110/80, oxygen saturation 97% on room air, respiratory rate 18, and pain rating of 2 on 1-10 scale. Which patient finding below requires you to notify the physician? A. The patient reports blurred vision. B. The patient is having difficulty passing stool and reports constipation. C. The patient reports that the eyes feel itchy. D. The patient's eyes are frequently tearing up.

B. The patient is having difficulty passing stool and reports constipation. Option A, C, and D are NORMAL findings that can occur after glaucoma surgery. The patient should avoid activities that can increase intraocular pressure like bending, straining (especially during bowel movements), or lifting heavy objects. Therefore, the nurse would need to notify the doctor to obtain an order for a laxative or stool softener so the patient won't strain during a bowel movement.

A patient asks you to explain how the intraocular pressure is measured to help detect glaucoma. You state that IOP (intraocular pressure) is measured by what instrument below? A. Goniscope B. Tonometry C. Ophthalmoscope D. Phoroptor

B. Tonometry A tonometer is used to assessment IOP.

A patient with Stage 5 CKD is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood? A. Calcium B. Urea C. Phosphate D. Erythropoietin

B. Urea This patient is experiencing uremic frost that occurs in severe chronic kidney disease. This is due to high amounts of urea in the blood being secreted via the sweat glands onto the skin, which will appear as white deposits on the skin. The patient will experience itching with this.

Which patient below is NOT at risk for developing chronic kidney disease? A. A 58 year old female with uncontrolled hypertension. B. A 69 year old male with diabetes mellitus. C. A 45 year old female with polycystic ovarian disease. D. A 78 year old female with an intrarenal injury.

C. A 45 year old female with polycystic ovarian disease. Options A, B, and D are all at risk for developing CKD. However, option C is not at risk for CKD.

A patient is experiencing a severe case of acute angle-closure glaucoma. The patient is not a candidate for laser intervention. The nurse would anticipate the physician would order the nurse to prep the patient for what procedure? A. Trabeculoplasty B. Trabeculectomy C. Iridectomy D. Blepharoplasty

C. Iridectomy Iridectomy is where the surgeon removes part of the iris which will help drain off aqueous humor and decrease the IOP. Options A and B are procedures to help treat open-angle glaucoma. Option C is used to treat angle-closure glaucoma and is more invasive than the laser procedure called a laser iridotomy (it's where a small hole is created in the iris with a laser to drain the increased aqueous humor). We are told in the scenario the patient is not a candidate for this procedure.

A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be A. Adding a daytime nap. B. Allowing the child to sleep longer in the morning. C. Maintaining the child's home sleep routine. D. Offering the child a bedtime snack.

C. Maintaining the child's home sleep routine. Pediatric patients require routines. It is normal for pediatric patients to go through phases of resisting sleep.

A 55 year old male patient is diagnosed with chronic kidney disease. The patient's recent GFR was 25 mL/min. What stage of chronic kidney disease is this known as? A. Stage 1 B. Stage 3 C. Stage 4 D. Stage 5

C. Stage 4 This is known as Stage 4 of CKD because the GFR (glomerular filtration rate) for this stage is 15-29 mL/min (patient's GFR is 25 mL/min). The other stage's criteria are as follows: Stage 1: Kidney damage with normal renal function GFR >90 ml/min but with proteinuria (3 months or more); Stage 2: Kidney damage with mild loss of renal function GFR 60-89 ml/min with proteinuria (3 months or more); Stage 3: Mild-to-severe loss of renal function GFR 30-59 mL/min; Stage 4: Severe loss renal function GFR 15-29 mL/min; Stage 5: End stage renal disease GRF less 15 mL/min.

What signs and symptoms are present with angle-closure glaucoma? Select all that apply: A. Patients are mainly asymptomatic B. Gradual loss of peripheral vision C. Sudden vision changes (halos around lights or blurred vision) D. Severe eye pain E. Corneal edema F. Nausea and vomiting G. Red eyes H. No pain I. IOP <10 mmHg

C. Sudden vision changes (halos around lights or blurred vision) D. Severe eye pain E. Corneal edema F. Nausea and vomiting G. Red eyes Angle-closure glaucoma is SUDDEN and SEVERE. The patient will NOT be asymptomatic like in open-angle glaucoma. They will have SUDDEN vision changes, severe pain (eyes or head), corneal edema, nausea/vomiting, red eyes, and IOP >50 mmHg. It is a medical emergency.

The production and drainage rate of aqueous humor is not equal in patients with glaucoma. Select below the correct sequence for how aqueous humor should flow through the eye: A. The ciliary body produces aqueous humor -> then it flows through the anterior chamber (area of the eye between the iris and cornea) -> pupil opening -> posterior chamber (area of the eye between lens and iris) ->drainage angle ->trabecular meshwork -> schlemm's canal -> episcleral veins B. The lens produces aqueous humor -> then it flows through the pupil opening -> the anterior chamber (area of the eye between the iris and cornea) -> posterior chamber (area of the eye between lens and iris) -> drainage angle ->trabecular meshwork -> schlemm's canal -> episcleral veins C. The ciliary body produces aqueous humor -> then it flows through the posterior chamber (area of the eye between the lens and iris) -> pupil opening -> anterior chamber (area of the eye between iris and cornea) -> drainage angle ->trabecular meshwork -> schlemm's canal -> episcleral veins D. The lens produces aqueous humor -> then it flows through the posterior chamber (area of the eye between the iris and cornea) -> pupil opening -> anterior chamber (area of the eye between lens and iris) -> drainage angle ->trabecular meshwork -> schlemm's canal -> episcleral veins

C. The ciliary body produces aqueous humor -> then it flows through the posterior chamber (area of the eye between the lens and iris) -> pupil opening -> anterior chamber (area of the eye between iris and cornea) -> drainage angle ->trabecular meshwork -> schlemm's canal -> episcleral veins This is the correct sequence for how aqueous humor flows through the eye

Which statement below is CORRECT about glaucoma? A. "The vision loss that occurs with glaucoma is reversible with eye drop medications." B. "Glaucoma occurs due to decreased intraocular pressure, which damages the optic nerve." C. "Surgery can cure glaucoma." D. "A normal intraocular pressure is about 10-21 mmHg and is elevated in most patients with glaucoma."

D. "A normal intraocular pressure is about 10-21 mmHg and is elevated in most patients with glaucoma." This option is the only correct statement about glaucoma. Vision loss is NOT reversible when it occurs in glaucoma but it's permanent...eye drops can prevent further progression. Glaucoma occurs due to INCREASED intraocular pressure (NOT decreased), and there is NO cure for glaucoma.

You're providing an educational seminar to a group of senior citizens about glaucoma. You explain to the participants about the differences between open-angle and angle-closure glaucoma in relation to the drainage angle of the eye. A participant asks what type of examination can be performed to assess the drainage angle of the eye. Your response is? A. Tonometry B. Ophthalmoscopy C. Retinoscopy D. Gonioscopy

D. Gonioscopy A gonioscopy is used to assess the drainage angle of the eye. The drainage angle is the area in which an angle is formed at the front of the eyes where the iris and cornea meet. This is where aqueous humor drains out into the trabecular meshwork.

The kidneys are responsible for performing all the following functions EXCEPT? A. Activating Vitamin D B. Secreting Renin C. Secreting Erythropoietin D. Maintaining cortisol production

D. Maintaining cortisol production The adrenal glands are responsible for maintaining cortisol production not the kidneys.

Your patient with chronic kidney disease is scheduled for dialysis in the morning. While examining the patient's telemetry strip, you note tall peaked T-waves. You notify the physician who orders a STAT basic metabolic panel (BMP). What result from the BMP confirms the EKG abnormality? A. Phosphate 3.2 mg/dL B. Calcium 9.3 mg/dL C. Magnesium 2.2 mg/dL D. Potassium 7.1 mEq/L

D. Potassium 7.1 mEq/L The patient's potassium level is extremely elevated. A normal potassium level is 3.5-5.1 mEq/L. This patient is experiencing hyperkalemia, which can cause tall peak T-waves. Remember in CKD (especially prior to dialysis), the patient will experience electrolyte imbalances, especially hyperkalemia.

During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as A. Cataplexy. B. Insomnia. C. Narcolepsy. D. Sleep apnea.

D. Sleep apnea. Sleep apnea occurs when a patient stops breathing for 1 to 2 minutes or more while sleeping.

You're observing a patient self-administer eye drops for the treatment of glaucoma. Which finding below requires you to re-educate the patient on how to administer eye drops correctly? A. The patient refrains from blinking after instilling the eye drops. B. The patient washes hands before and after administering the eye drops. C. The patient uses a tissue to catch any medication that drips out of the eye after administration of the drops. D. The patient places the drops of medication directly on the eye via the cornea.

D. The patient places the drops of medication directly on the eye via the cornea. Eye drops are placed in the lower sac of the eye (conjunctival sac) NOT directly on the eye via the cornea. It's important that the nurse observes the patient using the drops and re-educate if they are using them incorrectly.

Your patient, who has open-angle glaucoma, is scheduled for a procedure that will remove some of the trabecular meshwork and create an opening to allow aqueous humor to collect in an area of the conjunctiva. This procedure will allow aqueous humor to be reabsorbed and help decrease IOP. As the nurse you know that you will need to provide pre-op and post-op patient education about what procedure below? A. Iridectomy B. Selective Laser Trabeculoplasty (SLT) C. Laser iridotomy D. Trabeculectomy

D. Trabeculectomy Trabeculectomy This procedure can help decrease IOP pressure in the eyes, and is used when eye drops or other procedures are not working.

A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect? a. Redness and swelling of the conjunctiva b. Drooping of the upper lid margin in one or both eyes c. Redness, swelling, and crusting along the eyelid margins d. Small, superficial white nodules along the eyelid margin

Drooping of the upper lid margin in one or both eyes Ptosis is the term used to describe drooping of the upper eyelid margin, which may be either unilateral or bilateral. Ptosis can be a result of mechanical causes, such as an eyelid tumor or excess skin, or from myogenic causes such as myasthenia gravis. Redness, swelling of the conjunctive, or crusting along the eyelid margins may indicate an infection such as viral or bacterial conjunctivitis. Small superficial white nodules along the eyelid margin may indicate hordeolum (sty).

Which question would the nurse ask to determine a client's potential for injury because of sleep deprivation? Select all that apply. One, some, or all answers may be correct. a. "Do you operate heavy machinery at work?" b. "What activities do you do in your spare time?" c. "Do you feel the need to take naps during the day?" d. "Does sleepiness affect your performance at work?" e. "How many hours of sleep do you get every night?"

a. "Do you operate heavy machinery at work?" c. "Do you feel the need to take naps during the day?" The nurse would ask about operating heavy machinery at work or whether sleepiness affects the client's ability to work. Sleep deprivation is unlikely to affect a client's hobbies and activities. Information on naps and knowing how many hours of sleep the client gets can help determine a client's sleep requirements, but this information would not determine the potential for injury.

Which question is most appropriate when the nurse is assessing a patient who is receiving care for suspected obstructive sleep apnea (OSA)? a. "Do you smoke?" b. "Do you tend to awaken early in the morning?" c. "Are you under a lot of stress at work or at home right now?" d. "Do you have a history of chronic obstructive pulmonary disease?"

a. "Do you smoke?" Smoking is a major etiologic factor in OSA. Early wakening and stress are associated with insomnia, not OSA in particular. COPD exacerbates the hypoxemia associated with OSA but does not precipitate the onset of OSA itself.

A 22-yr-old patient tells the nurse at the health clinic that he has recently had problems with erectile dysfunction. Which question should the nurse ask to assess for possible etiologic factors in this age group? a. "Do you use recreational drugs or drink alcohol?" b. "Do you experience an unusual amount of stress?" c. "Do you have cardiovascular or peripheral vascular disease?" d. "Do you have a history of an erection that lasted for 6 hours or more?"

a. "Do you use recreational drugs or drink alcohol?" A common cause of erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men.

A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is appropriate? a. "Have you taken any over-the-counter (OTC) medications recently?" b. "I will talk to the doctor about a prostate-specific antigen (PSA) test." c. "Have you talked to the doctor about surgery such as transurethral resection of the prostate (TURP)?" d. "The prostate gland changes in size from day to day, and this may be making your symptoms worse."

a. "Have you taken any over-the-counter (OTC) medications recently?" Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer.

The nurse is assessing a 65-yr-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. "Hold this card and read the print out loud." b. "Cover one eye while reading the wall chart." c. "You'll feel a short burst of air directed at your eyeball." d. "A light will be used to look for a change in your pupils."

a. "Hold this card and read the print out loud." The Jaeger card is used to assess near vision problems and presbyopia in persons older than 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

Which statement by the adolescent indicates a need for further teaching about the importance of sleep? a. "I need 7 hours of sleep each night" b. "Not getting enough sleep can affect my grades" c. "Sleep deprivation can affect my physical health" d. "I should leave my phone in the other room to improve my sleep"

a. "I need 7 hours of sleep each night" Adolescents need around 9 hours of sleep each night, although many teens get less than that. Not getting enough sleep can affect school performance and mental and physical health. Many factors cause a teen to not get the sleep he or she needs, including homework, extracurricular activities, time with friends, and use of electronic devices. Leaving the phone in the other room at bedtime can help improve quantity and quality of sleep.

A 70-yr-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today. Which patient statement indicates a need for the nurse to provide additional instruction? a. "I should call the doctor if I have incontinence at home." b. "I will avoid driving until I get approval from my doctor." c. "I should schedule yearly appointments for prostate examinations." d. "I will increase fiber and fluids in my diet to prevent constipation."

a. "I should call the doctor if I have incontinence at home." Because incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions.

Which medications can lead to development of tinnitus? (Select all that apply.) a. Furosemide b. Vancomycin c. Insulin glulisine d. Docusate sodium e. Naproxen sodium

a. Furosemide b. Vancomycin e. Naproxen sodium Ototoxic medications, such as analgesics, antibiotics (such as vancomycin and aminoglycosides), or diuretics, affect hearing acuity, balance, or both, with the most common symptom being tinnitus (ringing in the ears). Surgical anesthesia, morphine, and docusate sodium do not have the side effect of ototoxicity or tinnitus.

A 65-yr-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment plan? a. "I take metoprolol (Lopressor) for angina." b. "I take aspirin when I have a sinus headache." c. "I have had frequent episodes of conjunctivitis." d. "I have not had an eye examination for 10 years."

a. "I take metoprolol (Lopressor) for angina." It is important to note whether the patient takes any E-adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, treatment will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

The nurse is caring for a client who has been sleeping for 12 to 14 hours on weekend nights. The nurse instructs the client to sleep for no longer than 9 hours because excessive sleeping can lead to health issues. Which reaction might the nurse expect if the client is in the maintenance stage? a. "I've been following a proper sleep pattern for more than a year" b. "I like to sleep; that's why I doze. I just don't care about all this health advice" c. " I've tried to follow a proper sleep routine, but I end up sleeping for more than 12 hours" d. "Please suggest a regimen that can help me stay awake or will help me normalize my sleep pattern"

a. "I've been following a proper sleep pattern for more than a year" In the maintenance stage, the client is able to sustain changes and wants to integrate them into his or her lifestyle. If the client says that he or she has been following a proper sleep routine for more than a year, the client has reached the maintenance stage. If the client says that he or she dozes because he or she likes to sleep, the client is in the precontemplation stage. If the client says that he or she is trying to follow a proper sleep routine but still ends up sleeping for more than 12 hours, the client is in the action stage. If the client asks the nurse to suggest a regimen that can help him or her stay awake or normalize his sleep pattern, the client is in the preparation stage.

The healthcare provider prescribes finasteride for a client with benign prostatic hyperplasia (BPH). The client would like to take saw palmetto instead of the finasteride. Which information would the nurse provide to the client about this herbal supplement? a. "Research has shown that saw palmetto is no better than a placebo" b. "You can take both; saw palmetto doesn't require a prescription" c. "The herbal supplement will relieve symptoms by altering the size of the prostate" d. "Substituting saw palmetto is a good option to avoid all the bad side effects of finasteride"

a. "Research has shown that saw palmetto is no better than a placebo" Rigorous research has demonstrated no significant difference between saw palmetto and a placebo. The health care provider must be consulted regarding the client's desire to change the prescribed therapy. Saw palmetto should be taken with food to limit gastrointestinal side effects. Saw palmetto does not alter the size of the prostate gland. Substituting something that is ineffective is not a good solution regardless of issues surrounding side effects.

The nurse is testing the visual acuity of a patient in the outpatient clinic. Which instructions should the nurse give for this test? a. "Stand 20 feet away from the wall chart." b. "Look at an object far away and then near to you." c. "Follow the examiner's finger with your eyes only." d. "Look straight ahead while I check your eyes with a light."

a. "Stand 20 feet away from the wall chart." When the Snellen chart is used to check visual acuity, the patient should stand 20 ft away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements.

A new mother is exhausted because her 4-week-old infant is unable to sleep through the night. Which is the best recommendation of the nurse? a. "Try to sleep when your baby is sleeping." b. "Try keeping the room warm during the night." c. "Try not to let your baby nap during the day." d. "Try laying the baby on his stomach at night."

a. "Try to sleep when your baby is sleeping." Infants usually develop a nighttime pattern of sleep by 3 to 4 months of age. The neonate and infant up to the age of 3 months average about 16 to 18 hours of sleep a day. The mother should be encouraged to sleep when the baby is sleeping. Infants sleep best when the room temperature is 18° C to 21° C (64° F to 70° F). The infant is likely to become irritable and overtired if napping during the day is prevented. Infants should be laid on their backs to sleep to prevent Sudden Infant Death Syndrome.

The nurse working in the clinic receives telephone calls from several patients who want appointments as soon as possible. Which patient should be seen first? a. 71-yr-old who has noticed increasing loss of peripheral vision b. 74-yr-old who has difficulty seeing well enough to drive at night c. 60-yr-old who is reporting dry eyes with decreased tear formation d. 64-yr-old who states that it is becoming difficult to read news print

a. 71-yr-old who has noticed increasing loss of peripheral vision Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbyopia, decreased tear formation, and impaired night vision.

The following male patients recently arrived in the emergency department. Which one should the nurse assess first? a. A 19-yr-old patient who is reporting severe scrotal pain b. A 60-yr-old patient with a nontender ulceration of the glans penis c. A 64-yr-old patient who has dysuria after brachytherapy for prostate cancer d. A 22-yr-old patient who has purulent urethral drainage and severe back pain

a. A 19-yr-old patient who is reporting severe scrotal pain The patient's age and symptoms suggest possible testicular torsion, which will require rapid treatment to prevent testicular necrosis. The other patients also require assessment by the nurse, but their history and symptoms indicate nonemergent problems (acute prostatitis, cancer of the penis, and radiation-associated urinary tract irritation).

Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm arteriovenous fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

a. Auscultate for a bruit at the fistula site. The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first? a. A 22-yr-old patient who has noticed a firm, nontender lump on his scrotum b. A 35-yr-old patient who is concerned that his scrotum "feels like a bag of worms" c. A 40-yr-old patient who has pelvic pain while being treated for chronic prostatitis d. A 70-yr-old patient who is reporting frequent urinary dribbling after a prostatectomy

a. A 22-yr-old patient who has noticed a firm, nontender lump on his scrotum The patient's age and symptoms suggest possible testicular cancer. Some forms of testicular cancer can be very aggressive, so the patient should be evaluated by the health care provider as soon as possible. Varicoceles do require treatment but not emergently. Ongoing pelvic pain is common with chronic prostatitis. Urinary dribbling is a common problem after prostatectomy.

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can be used sooner after surgery. d. A fistula can accommodate larger needles.

a. A fistula is much less likely to clot. Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

A male patient reports fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)? a. A very tender prostate gland b. Reports of chills and rectal pain c. Reports of urgency and frequency d. Escherichia coli bacteria in his urine

a. A very tender prostate gland A tender and swollen prostate is indicative of prostatitis, which is a more serious male reproductive problem because an acute episode can result in chronic prostatitis and lead to epididymitis or cystitis. E. coli in his urine, chills and rectal pain, and urgency and frequency are all present with a UTI and not specifically indicative of prostatitis.

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? a. Absence of pain or pressure b. Blurred vision in the morning c. Seeing colored halos around lights d. Eye pain accompanied with nausea and vomiting

a. Absence of pain or pressure Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma signs and symptoms include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.

The patient reports a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? a. Amsler grid test b. B-scan ultrasonography c. Fluorescein angiography Intraocular pressure testing with d. Tono-PenIncorrect Answer

a. Amsler grid test The Amsler grid test is self-administered and regular testing is necessary to identify any changes in macular function. B-scan ultrasonography is used to diagnose ocular pathologic conditions (e.g., intraocular foreign bodies or tumors, vitreous opacities, retinal detachments). Fluorescein angiography is used to diagnose problems related to the flow of blood through pigment epithelial and retinal vessels. Intraocular pressure testing with a Tono-Pen is done to test for glaucoma.

Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD)? (Select all that apply.) a. Anemia b. Dehydration c. Hypertension d. Hypercalcemia e. Increased fracture risk f. Elevated white blood cells

a. Anemia c. Hypertension e. Increased fracture risk When the kidney fails, erythropoietin is not excreted, so anemia is expected. Dehydration and hypercalcemia are not expected in chronic renal disease. Fluid volume overload with hypertension and hypocalcemia are expected. Hypocalcemia from chronic renal disease stimulates the parathyroid to release parathyroid hormone, causing calcium liberation from bones increasing the risk of pathological fracture. Although impaired immune function should be expected, elevated white blood cells would indicate inflammation or infection not associated with chronic renal failure itself but a complication.

A nurse has been temporarily assigned to the night shift. A change in this circadian rhythm may cause which of the following? (Select all that apply.) a. Anxiety b. Weight gain c. Decreased appetite d. Impaired judgment e. Increased periods of sleep

a. Anxiety c. Decreased appetite d. Impaired judgment When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other physiological functions change as well. For example, a new nurse who starts working the night shift experiences a decreased appetite and loses weight, not weight gain. Anxiety, restlessness, irritability, and impaired judgment are other common symptoms of sleep cycle disturbances. Decreased, not increased, periods of sleep can occur. Failure to maintain an individual's usual sleep-wake cycle negatively influences the person's overall health.

A with stage 3 CKD is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? a. Apple, green beans, and a roast beef sandwich b. Granola made with dried fruits, nuts, and seeds c. Watermelon and ice cream with chocolate sauce d. Bran cereal with ½ banana and milk and orange juice

a. Apple, green beans, and a roast beef sandwich When the patient selects an apple, green beans, and a roast beef sandwich, the patient shows understanding of the low-potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have high levels of potassium, at or above 200 mg per 1/2 cup.

A patient with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform? a. Assess the patient's hydration status. b. Insert a urinary catheter for the expected diuresis. c. Evaluate the patient's lower extremities for edema. d. Check the patient's urine for the presence of ketones.

a. Assess the patient's hydration status. Preexisting kidney disease is the most important risk factor for the development of contrast-associated nephropathy and nephrotoxic injury. If contrast media must be administered to a high-risk patient, the patient needs to have optimal hydration. The nurse should assess the hydration status of the patient before the procedure is performed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis? (Select all that apply.) a. Avoid commercial salt substitutes. b. Restrict fluid intake to 1000 mL daily. c. Take phosphate binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.

a. Avoid commercial salt substitutes. c. Take phosphate binders with each meal. d. Choose high-protein foods for most meals. Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is not limited unless weight and blood pressure are not controlled. Dairy products are high in phosphate and usually are limited.

The nurse is caring for a 62-yr-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? a. Avoid straining during defecation. b. Restrict fluids to prevent incontinence. c. Sexual functioning will not be affected. d. Prostate examinations are not needed after surgery.

a. Avoid straining during defecation. Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period to prevent a postoperative hemorrhage. Teach the patient to drink at least 2 L of fluid every day. Digital rectal examinations should be performed yearly. The prostate gland is not totally removed and may enlarge after a TURP. Sexual functioning may change after prostate surgery. Changes may include retrograde ejaculation, erectile dysfunction, and decreased orgasmic sensation.

What is the priority problem for a patient experiencing an acute attack with Meniere's disease? a. Being at risk for falls b. Imbalanced nutritional intake c. Difficulty performing self-care d. Impaired verbal communication

a. Being at risk for falls All the problems are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness.

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medication? a. Bowel sounds b. Blood glucose c. Blood urea nitrogen (BUN) d. Level of consciousness (LOC)

a. Bowel sounds Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse's decision to give the medication.

Which bedtime snack will best help the patient to fall asleep easily? a. Bowl of cereal with milk b. Ham sandwich, fruit, and juice c. Glass of red wine with wheat crackers d. Chocolate chip cookies and a cup of hot tea

a. Bowl of cereal with milk A bedtime snack containing protein and carbohydrates such as cereal and milk or cheese and crackers, which contain L-tryptophan, may help to promote sleep. A full meal before bedtime often causes gastrointestinal upset and interferes with the ability to fall asleep. Coffee, tea, cola, and chocolate cause a person to stay awake or wake up throughout the night. Alcohol disrupts sleep patterns and can make it difficult to fall asleep.

What information will the nurse plan to teach the patient scheduled for photovaporization of the prostate (PVP)? a. Care of an indwelling urinary catheter. b. Urine will appear bloody for several days. c. Symptom improvement takes 2 to 3 weeks. d. Complications associated with urethral stenting.

a. Care of an indwelling urinary catheter. The patient will have an indwelling catheter for 24 to 48 hours and will need teaching about catheter care. There is minimal bleeding with this procedure. Symptom improvement is almost immediate after PVP. Stent placement is not part of the procedure.

Which assessment findings lead the nurse to suspect that the patient has obstructive sleep apnea? a. Daytime sleepiness, snoring, and obesity b. Insomnia, inability to concentrate, and anemia c. Early morning awakening, shift work, and attention deficit disorder (ADD) d. Latex allergy, stressful career, and recent divorce

a. Daytime sleepiness, snoring, and obesity Daytime sleepiness and snoring in an overweight patient indicates the strong possibility of sleep apnea. The patient should be referred for further testing. Insomnia, early morning awakening, and stressful career do not lead to sleep apnea.

An older adult patient in the hospital has sleep deprivation. Which intervention may improve sleep patterns for this patient? a. Decrease noise and dim the lights at bedtime. b. Administer an opioid pain medication to induce sleep. c. Set the room temperature at 78°F to induce drowsiness. d. Offer to give the patient a back massage until he falls asleep.

a. Decrease noise and dim the lights at bedtime. Decreasing noise and dimming the lights will help create a calm and relaxed environment for the patient.

Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI)? (Select all that apply.) a. Dehydration b. Hypokalemia c. Hypernatremia d. BUN increases e. Urine output increases f. Serum creatinine increases

a. Dehydration b. Hypokalemia e. Urine output increases The hallmark of entering the diuretic phase is the production of copious amounts of urine. Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Serum BUN and serum creatinine levels begin to decrease.

A patient who has Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 45 degrees.

a. Dim the lights in the patient's room. A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort.

What side effect of leuprolide (Lupron) should the nurse plan to discuss with a patient who has cancer of the prostate? a. Flushing b. Dizziness c. Infection d. Incontinence

a. Flushing Hot flashes may occur with decreased testosterone production. Dizziness may occur with the D-blockers used for benign prostatic hyperplasia. Urinary incontinence may occur after prostate surgery, but it is not an expected side effect of medication. Risk for infection is increased in patients receiving chemotherapy.

The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? a. Discard all opened or used lens care products. b. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. c. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. d. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.

a. Discard all opened or used lens care products. The patient who wears contact lenses and develops infections should discard all opened or used lens care products and cosmetics to decrease the risk of reinfection from contaminated products. The risk of conjunctivitis is increased with not disinfecting lenses properly, wearing contact lenses too long, or using water or homemade solutions to store and clean lenses.

A college student reports eye pain after studying for finals. What assessment should the nurse make first in determining the possible cause of this eye pain? a. Do you wear contacts? b. Do you have any allergies? c. When was your last eye exam? d. Describe the changes in your vision.

a. Do you wear contacts? College students frequently wear contact lenses and stay up late or all night studying for finals. If the student wears contacts, the wearing of them while studying, care of them, and length of wear time will be assessed before looking for a corneal abrasion from extended wear with fluorescein dye. There are no manifestations of allergies or visual changes mentioned.

Which nighttime activity will keep the patient from being able to fall asleep easily? a. Doing crossword puzzles on a tablet computer b. Turning down the temperature in the bedroom c. Listening to recordings of soothing classical music d. Always going to bed at approximately the same time

a. Doing crossword puzzles on a tablet computer Doing crossword puzzles on a tablet computer engages the brain and makes it hard to fall asleep. In addition, the bright background light of the computer screen interferes with the brain's ability to fall asleep. Turning down the temperature in the bedroom and listening to soothing music will facilitate falling asleep. Keeping a consistent bedtime will also help the body to relax and fall asleep.

Which recommendation would the nurse suggest to a menopausal client experiencing insomnia? Select all that apply. One, some, or all responses may be correct. a. Drink chamomile tea b. Avoid caffeine after dinner c. Restrict liquids in the evening d. Sprinkle lavender oil on a pillow e. Use the bed for sleeping and sex only

a. Drink chamomile tea b. Avoid caffeine after dinner c. Restrict liquids in the evening d. Sprinkle lavender oil on a pillow e. Use the bed for sleeping and sex only Insomnia is common during menopause. To help manage sleeping problems, clients would be advised to avoid caffeine and try soothing hot drinks like chamomile tea, limit liquids in the evening, sprinkle lavender oil on their pillow, and reserve the bed for sleeping and sexual intercourse only.

Which activity should be avoided by older adults due to age-related vision changes? a. Driving after dark b. Digital photography c. Typing on the computer d. Doing crossword puzzles

a. Driving after dark Visual changes often include reduced visual fields, increased glare sensitivity, impaired night vision, reduced accommodation, reduced depth perception, and reduced color discrimination. Many of these symptoms occur because the pupils in the older adult take longer to dilate and constrict secondary to weaker iris muscles. For this reason the older adult should be encouraged to avoid driving after dark. Reading glasses are often required for typing and writing. Digital photography is not affected by age-related vision changes.

What teaching should be included in the plan of care for a patient with narcolepsy? a. Driving an automobile may be possible with appropriate treatment of narcolepsy. b. Changes in sleep hygiene are ineffective in improving sleep quality in narcolepsy. c. Antidepressant drugs are prescribed to treat the depression caused by the disorder. d. Stimulant drugs should be used for less than a month because of the risk for abuse.

a. Driving an automobile may be possible with appropriate treatment of narcolepsy. The accident rate FOR patients with narcolepsy who are receiving appropriate treatment is similar to the general population. Stimulant medications are used on an ongoing basis for patients with narcolepsy. The purpose of antidepressant drugs in the treatment of narcolepsy is the management of cataplexy, not to treat depression. Changes in sleep hygiene are recommended for patients with narcolepsy to improve sleep quality.

What principle should guide the nurse's practice when providing care for older patients with sleep problems? a. Drug therapy should be used conservatively. b. Older adults require less sleep than younger adults. c. Cognitive-behavioral interventions are less effective than among younger adults. d. Patient teaching should focus on older adults accepting age-related changes in their sleep cycles.

a. Drug therapy should be used conservatively. Drug therapy for sleep problems should be used conservatively in older adults. They do not necessarily need less sleep, and cognitive-behavioral therapies should still be used. Changes in sleep cycles do accompany aging, but teaching should not simply focus on accepting, rather than addressing, these changes.

A patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? a. Eat a light meal before the procedure. b. Avoid carbonated beverages before the procedure. c. Take nothing by mouth for 3 hours before the procedure. d. No special dietary restrictions are needed until after the procedure.

a. Eat a light meal before the procedure. Teach patient to eat a light meal before the test to avoid nausea. Results of vestibular tests can be altered by use of caffeine, other stimulants, sedatives, and antivertigo drugs.

Which findings from the client's history would be symptoms of insomnia disorder? Select all that apply. One, some, or all responses may be correct. a. Fatigue b. Panic attacks c. Acute pain d. Early morning awakenings e. Reduced concentration f. Irritability

a. Fatigue d. Early morning awakenings e. Reduced concentration f. Irritability Symptoms of insomnia disorder include fatigue, early morning awakenings, reduced concentration, and irritability. Insomnia disorder is caused by emotional or physical stress not related to the direct physiological effects of a substance or illness or mental health disorder. Symptoms of insomnia disorder that the nurse might assess in this client would be fatigue, early morning awakenings, reduced concentration, and irritability. The DSM-5 criteria for insomnia disorder states that the insomnia is not attributable to another mental disorder (panic attacks) or medical conditions (acute pain).

hat information should the nurse include when performing discharge teaching for a patient after a vasectomy? a. He should continue to use other methods of birth control for 6 weeks. b. He should not have sexual intercourse until his 6-week follow-up visit. c. He may have temporary erectile dysfunction (ED) because of swelling. d. He will notice a decrease in the appearance and volume of his ejaculate.

a. He should continue to use other methods of birth control for 6 weeks. Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the patient should use contraception for 6 weeks. ED that occurs after vasectomy is psychologic in origin and not related to postoperative swelling. The patient does not need to abstain from intercourse. The appearance and volume of the ejaculate are not changed because sperm are a minor component of the ejaculate.

A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? a. Hearing loss b. Exophthalmos c. Conjunctivitis d. Recurrent fever

a. Hearing loss Aminoglycosides such as gentamicin are drugs that are potentially ototoxic and may cause damage to the auditory nerve. When this drug is used, careful monitoring for hearing and balance problems (e.g., hearing loss, tinnitus, vertigo) is essential. Exophthalmos is related to a symptom of hyperthyroidism. Conjunctivitis is a bacterial or a viral infection of the conjunctiva. Recurrent fever can be related to many issues and is not related to the use of IV gentamicin.

The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? a. Hypertension and diabetes b. Hypothyroidism and polycythemia c. Atrial fibrillation and atherosclerosis d. Vascular dementia and chronic fatigueIncorrect Answer

a. Hypertension and diabetes Hypertension and diabetes frequently contribute to visual pathologies. The other health problems are less likely to have a direct, deleterious effect on a patient's vision.

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. Which sleep promotion technique would the nurse advise? a. Include age-appropriate exercise daily b. Read in bed before sleeping c. Avoid naps during the daytime d. Have a hot cup of tea at bedtime

a. Include age-appropriate exercise daily Exercise, such as walking or other activity appropriate for the older adult, will be invigorating during the day and prime the client for a better night's sleep. Reading is relaxing before sleeping, but the client should avoid reading in bed; the client should establish a pattern of using the bed to sleep. Naps should be limited, but not necessarily eliminated; research has demonstrated that a short nap (20-30 minutes) in the afternoon will not appreciably affect nighttime sleep. The client should avoid caffeinated beverages before bedtime because caffeine is a stimulant that generally interferes with sleep.

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hr.

a. Insert urethral catheter. The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of an indwelling catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions are appropriate but should be implemented after the catheter.

An older adult patient states they do not seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? a. Look for cerumen in the ear. b. Assess for increased hair growth in the ear. c. Tell the patient it is probably related to aging. d. Ask the patient if he has fallen because of dizziness.

a. Look for cerumen in the ear. Gerontologic differences in the assessment of the auditory system include increased production of and drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly as the patient's voice conducted through bone seems loud to the patient. Although increased hair growth occurs, it will not impact the hearing. Presbycusis may be occurring, but it should not be assumed. There is no reason to ask the patient if he has fallen because dizziness and vertigo are not a normal change of aging of the ear.

Which is the safest sleep aid for the elderly patient with insomnia? a. Melatonin b. Trazodone c. Temazepam d. Triazolam

a. Melatonin Melatonin is the safest option for an elderly patient with insomnia although it is meant for short-term use. Trazodone can cause orthostatic hypotension. Temazepam and triazolam can cause cognitive impairment in older adults.

A client who has narcolepsy reports, "I often feel drowsy and fall asleep at inappropriate times". Which medication would the nurse anticipate will be prescribed by the primary health care provider for this client? a. Modafinil b. Ramelteon c. Eszopiclone d. Pramipexole

a. Modafinil Drowsiness and an inability to remain awake while performing activities are signs of narcolepsy. Modafinil is a medication used to promote wakefulness and combat narcolepsy. Pramipexole is a dopamine agonist used to treat periodic limb movement disorder. Eszopiclone is a benzodiazepine receptor-like agent, which is prescribed for insomnia. Ramelteon is a melatonin receptor agonist used to treat insomnia.

The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? a. Monitor the patient's cardiac status. b. Teach the patient about hand washing. c. Obtain a serum specimen for electrolytes. d. Increase direct observation of the patient.

a. Monitor the patient's cardiac status. The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. Which finding should the nurse record? a. OS 20/50; OD 20/40 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

a. OS 20/50; OD 20/40 When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye, and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.

What should the nurse plan to teach a 67-yr-old patient who has been diagnosed with orchitis? a. Pain management b. Emergency surgery c. Scrotal sac fluid aspiration d. Applying heat to the scrotum

a. Pain management Orchitis is very painful, and effective pain management will be needed. Heat, aspiration, and surgery are not used to treat orchitis.

A nurse is caring for a patient who suffers from a sleep pattern disturbance. To promote adequate sleep, what are the most appropriate nursing interventions? (Select all that apply.) a. Provide personal hygiene before bedtime. b. Straighten and change any soiled bed linens. c. Assist the patient to use the toilet before bed. d. Administer sleep aids every night at the same time. e. Synchronize the schedule for medications and vital signs.

a. Provide personal hygiene before bedtime. b. Straighten and change any soiled bed linens. c. Assist the patient to use the toilet before bed. e. Synchronize the schedule for medications and vital signs. You will make the patient more comfortable in an acute care setting by providing personal hygiene before bedtime. Have patients void before going to bed so they are not kept awake by a full bladder. Clean, dry linens make the patient comfortable for falling asleep. Medications and vital signs should be scheduled to wake the patient as infrequently as possible. Sleep aids should be avoided as they carry risk of side effects and long-term dependency.

Which are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. One, some, or all responses may be correct. a. Ptosis and blurred vision b. Agitation and hyperactivity c. Confusion and disorientation d. Increased sensitivity to pain e. Decreased auditory alertness

a. Ptosis and blurred vision e. Decreased auditory alertness Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

The nurse is caring for a patient who becomes agitated when visitors stay for extended periods or the hospital unit becomes noisy. The nurse identifies this as sensory overload. Which interventions will be of benefit to the patient? (Select all that apply.) a. Reduce the number of visitors to the patient's room. b. Provide a dedicated period of rest time each afternoon. c. Institute a unit-wide quiet time at 10:00 p.m. each night. d. Turn on the television to drown out noise from other patients. e. Coordinate therapies and tests with other departments and providers.

a. Reduce the number of visitors to the patient's room. b. Provide a dedicated period of rest time each afternoon. c. Institute a unit-wide quiet time at 10:00 p.m. each night. e. Coordinate therapies and tests with other departments and providers. Reduce sensory overload by organizing the patient's care to control for excessive stimuli. Reducing the number of visitors to the patient's room and instituting a unit-wide quiet time can help the patient to rest comfortably. Coordination with other departments will reduce the time needed for therapies and tests.

Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy? a. Reporting any bladder spasms b. Assessing the patient's incision c. Irrigating the patient's urinary catheter d. Evaluating the patient's pain and selecting analgesia

a. Reporting any bladder spasms Cleaning around the catheter, recording intake and output, and reporting any pain or bladder spasms to the registered nurse are appropriate tasks for delegation to the UAP. Selecting analgesia, irrigating the patient's catheter, and assessing the incision are not appropriate skills or tasks for unlicensed personnel.

A 71-yr-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a photoselective vaporization of the prostate. What is the primary goal of this intervention? a. Resumption of normal urinary drainage b. Maintenance of normal sexual functioning c. Prevention of acute or chronic renal failure d. Prevention of fluid and electrolyte imbalances

a. Resumption of normal urinary drainage The most significant signs and symptoms of BPH relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. A laser vaporization technique vaporizes prostate tissue and cauterizes blood vessels and is used as an effective alternative to a TURP to resolve these problems. Fluid imbalances, impaired sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.

A patient who underwent eye surgery must wear an eye patch until the scheduled postoperative clinic visit. Which patient problem will the nurse address in the plan of care? a. Risk for falls b. Difficulty coping c. Disturbed body image d. Inability to care for home

a. Risk for falls The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. This increases the risk for falls. There is no evidence in the assessment data for inability to care for home, disturbed body image, or difficulty coping.

Which is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking zolpidem? a. Risk for falls related to ambulating to kitchen while asleep b. Wandering related to cognitive impairment from sleeping aid c. Powerlessness related to inability to keep from eating during sleep d. Risk for imbalanced nutrition: more than body requirements related to sleep eating

a. Risk for falls related to ambulating to kitchen while asleep The highest priority nursing diagnosis is the risk for falls as serious injury may result. Wandering and powerlessness are less important than falls. Weight gain is less dangerous than the patient's risk of falling. Significant weight gain should not occur once the patient stops taking the medication.

Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea? a. Risk for impaired skin integrity related to tight-fitting mask on face b. Impaired bed mobility related to presence of CPAP mask on face c. Health-seeking behaviors related to expressed desire for better sleep d. Risk for powerlessness related to inability to breathe regularly during sleep

a. Risk for impaired skin integrity related to tight-fitting mask on face The CPAP mask can cause impaired skin integrity to the face unless it is applied and fitted correctly. The CPAP mask on the face will not cause impaired bed mobility. The patient is at low risk for powerlessness. Health-seeking behaviors are less important than the risk of skin breakdown.

Why is it important for a postoperative patient to get enough sleep after being discharged from the hospital? a. Sleep restores biological processes. b. Sleep stimulates appetite on waking. c. Sleep causes a mental and physiological calm. d. Sleep produces dreams that decrease epinephrine.

a. Sleep restores biological processes. Because the patient is postoperative, the primary reason for sleep is to help the body to heal by restoring biological processes. Sleep allows the body to restore biological processes. During deep slow-wave (NREM N3) sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. Protein synthesis and cell division for the renewal of tissues also occur during rest and sleep. The basal metabolic rate is lowered during sleep, which conserves the body's energy supply. REM sleep is important for cognitive restoration. During REM sleep, patients experience rapid eye movement, fluctuation in heart and respiratory rate, increased/fluctuating blood pressure, loss of skeletal muscle tone, and increase in gastric secretions. (This is not a mental and physical calm.) During REM sleep, there is increased oxygen consumption and epinephrine is released, not decreased. Sleep does not cause an increase in appetite as the metabolic rate slows down.

Which piece of assessment data from a client admitted for stress and anxiety requires a nursing intervention? a. Sleeping until 11:00am each day b. Exercising 160 minutes weekly c. Drinking 3 cups of coffee each day d. Getting 9 hours of sleep each night

a. Sleeping until 11:00am each day Sleeping late each morning is not necessarily helpful in getting more sleep and can actually disrupt body rhythms. A minimum of 150 minutes of exercise each week is recommended for everyone. Drinking 3 cups of coffee each day is within recommendation, but should be consumed in the morning to prevent difficulty sleeping at night. Seven to 9 hours of sleep each night is recommended for adults.

The nurse is reviewing a patient's medical history. Which medication findings are likely to cause insomnia? (Select all that apply.) a. Takes a beta-adrenergic blocker b. Takes a muscle relaxant c. Has antihistamine abuse d. Has a diuretic ordered in the a.m. e. Takes a benzodiazepine

a. Takes a beta-adrenergic blocker c. Has antihistamine abuse Beta-adrenergic blockers and antihistamines when used in excess can cause insomnia. Muscle relaxants and benzodiazepine can cause drowsiness. Diuretics do not cause insomnia but if administered late in the day can lead to nocturia, causing nighttime awakenings.

Which assessment findings put the patient at high risk for development of vision problems? (Select all that apply.) a. Takes insulin glulisine for type 1 diabetes. b. Takes metoprolol to treat hypertension. c. Takes docusate sodium for constipation. d. Takes acetaminophen for osteoarthritis pain. e. Takes prednisone for multiple sclerosis

a. Takes insulin glulisine for type 1 diabetes. b. Takes metoprolol to treat hypertension. e. Takes prednisone for multiple sclerosis History of diabetes and hypertension are both significant risk factors for eye diseases such as glaucoma and retinopathy. Prednisone is associated with early development of cataracts. Constipation, osteoarthritis, acetaminophen, and docusate sodium do not put the patient at high risk for vision problems.

The nursing instructor asks a student about the sleep pattern of teenagers. Which statements made by the student indicate adequate learning? Select all that apply. One, some, or all responses may be correct. a. Teenagers often have reduced hours of sleep b. Teenagers often suffer from restless leg syndrome c. Teenagers get an average of 7.5 hours of sleep each night d. Twenty percent of a teen's sleep cycle is rapid eye movement (REM) sleep e. Teenagers resist sleeping because they are unaware of fatigue

a. Teenagers often have reduced hours of sleep c. Teenagers get an average of 7.5 hours of sleep each night The typical adolescent is subject to a number of changes, such as school demands, after-school social activities, and part-time jobs, all which reduce the time spent sleeping. On average, teenagers get about 7.5 hours of sleep per night; preschoolers sleep an average of 12 hours a night. Restless leg syndrome is common in young adults, not teenagers. Young adults, not adolescents, have 20% of their sleep time in REM sleep. Preschoolers often resist sleeping because they are unaware of fatigue or have a need to be independent.

The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient report frequent "popping" in the ear. c. Clear fluid is visible through the tympanic membrane. d. The patient frequently asks the nurse to repeat information.

a. The patient has a temperature of 100.6° F. The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception? a. The patient must hold on to the railing when ambulating in the hallway. b. The patient must add extra seasoning to food in order for it to have any flavor. c. The patient did not smell smoke even though the smoke detector was alarming. d. The patient suffered a first-degree burn when a heating pad was left on too long.

a. The patient must hold on to the railing when ambulating in the hallway. Proprioception is the patient's ability to balance and maintain position. The patient's proprioception is affected when the patient is unable to ambulate without holding on to the handrail. Proprioception does not affect taste, smell, or sensation.

A 33-yr-old patient noticed a painless lump and heaviness in his scrotum during testicular self-examination. The nurse should provide the patient information on which diagnostic test? a. Ultrasound b. Cremasteric reflex c. Doppler ultrasound d. Transillumination with a flashlight

a. Ultrasound When the scrotum has a painless lump, scrotal swelling, and a feeling of heaviness, testicular cancer is suspected, and an ultrasound of the testes is indicated. Blood tests will also be done. The cremasteric reflex and Doppler ultrasound are done to diagnose testicular torsion. Transillumination with a flashlight is done to diagnose a hydrocele.

Which nursing intervention is appropriate for a patient with a history of parasomnia? a. Use of a bed alarm during the night b. Padded side rails for the patient's bed c. Use of a CPAP machine during the night d. Continuous pulse oximetry during the night

a. Use of a bed alarm during the night The parasomnias are sleep disorders that can occur during arousal from REM or partial arousal from NREM sleep. They include sleep walking, night terrors, nightmares, teeth grinding, and bed-wetting. A bed alarm is useful so that the nursing staff will be notified if the patient attempts to sleepwalk. Padded side rails, CPAP machine, and continuous pulse oximetry are not needed for parasomnia.

Which instruction should the nurse include in a teaching plan for a patient with herpes simplex keratitis? a. Wash hands frequently and avoid touching the eyes. b. Apply antibiotic drops to the eye several times daily. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

a. Wash hands frequently and avoid touching the eyes. The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus, and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications.

When performing presurgical teaching for a client pending a transurethral resection of the prostate (TURP), which statement would the nurse include? a. "Urinary control may be permanently lost to some degree" b. "An indwelling urinary catheter is required for at least 1 day" c. "Your ability to perform sexually will be impaired permanently" d. "Burning on urination will last while the cystostomy tube is in place"

b. "An indwelling urinary catheter is required for at least 1 day" The primary health care provider will insert a three-way indwelling urethral catheter because surgical trauma can cause edema and urinary retention, leading to additional complications such as bleeding. Urinary control is not lost in most cases; loss of control usually is temporary if it does occur. Sexual ability usually is not affected; the client maintains sexual ability if the client was able to perform sexually before the surgery. The procedure does not use a cystostomy tube if a client has a transurethral resection; however, the provider does use a cystostomy tube for a suprapubic resection.

The triage nurse at an ambulatory clinic receives a call from a person with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this potential eye injury? a. "Remove any visible metal fragments." b. "Apply a loose dressing over your eyes." c. "Rinse your eyes immediately with water." d. "Keep your eyes open to allow tears to form."

b. "Apply a loose dressing over your eyes." An initial intervention for a penetrating eye injury includes covering the eye(s) with a dry, sterile patch and protective shield. The fragments should not be removed by the person or others. Penetrating eye injuries should not be irrigated (only irrigate for chemical eye injuries).

A patient at the outpatient clinic reports insomnia and anxiety. He tells you that he recently lost his job and is not able to pay the bills. Which response would be the most appropriate? a. "You are healthy and will be able to find another job." b. "Can you tell me more about what is happening in your life?" c. "If you stop focusing on your problems, you will sleep better." d. "Did you receive a severance package from your employer?"

b. "Can you tell me more about what is happening in your life?" It is most appropriate for the nurse to validate and acknowledge the patient's feelings.

Which response would the nurse use when a client scheduled for a transurethral incision of the prostate (TUIP) voices concern regarding impotence? a. "It's understandable that your are worried; impotence is a very real possibility" b. "I can understand your concern, but this procedure usually does not cause impotence" c. "Most men worry about that ability; you should speak with your primary care health provider" d. "You may be temporarily impotent, but normal functioning returns within a few months"

b. "I can understand your concern, but this procedure usually does not cause impotence" The response "I can understand your concern, but this procedure usually does not cause impotence" recognizes the concern and provides accurate information that may reduce anxiety. The response "it's understandable that you are worried; impotence is a very real possibility" is inaccurate information; impotence usually does not result. The reply "most men worry about that ability; you should speak with your primary health care provider" closes off communication and transfers responsibility to the primary health care provider. The reply "You may be temporarily impotent, but normal functioning returns within a few months" does not recognize feelings and provides inaccurate information; impotence, rarely, if ever, occurs with this procedure.

The nurse teaches a patient with a sleep disorder about sleep hygiene. Which statement, if made by the patient, indicates understanding of the instructions? a. "I will go to bed at the same time whether I am sleepy or not." b. "I should set the temperature in my bedroom under 70° F at night." c. "I must stop drinking alcoholic beverages 2 hours before I go to bed." d. "I can use the prescribed sleeping pills every night to help me stay asleep."

b. "I should set the temperature in my bedroom under 70° F at night." Good sleep hygiene should include a cool, dark, and quiet bedroom; going to bed only when sleepy; avoiding sleeping pills or using them cautiously; and avoiding alcohol for at least 4 to 6 hours before bedtime.

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

b. "I will remove my contact lenses at bedtime." Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact.

Which patient statement indicates a need for further teaching about extended-release zolpidem (Ambien CR)? a. "I should take the medication on an empty stomach." b. "I will take the medication 1 to 2 hours before bedtime." c. "I should not take this medication unless I can sleep for at least 6 hours." d. "I will schedule activities that require mental alertness for later in the day."

b. "I will take the medication 1 to 2 hours before bedtime." Benzodiazepine receptor agonists such as zolpidem work quickly and should be taken immediately before bedtime. The other patient statements are correct.

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Checking for eye irritation in a patient with possible conjunctivitis

b. Application of a warm compress to a patient's hordeolum Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

A client who had a transurethral resection of the prostate (TURP) experiences dribbling after removal of the indwelling catheter. Which response to the client would the nurse use? a. "I know you're worried, but the dribbling will go away in a few days" b. "Increase your fluid intake and urinate at regular intervals" c. "Limit your fluid intake and urinate when you first feel the urge" d. "The catheter will have to be reinserted until your bladder regains its tone"

b. "Increase your fluid intake and urinate at regular intervals" The response "increase your fluid intake and urinate at regular intervals" will improve bladder tone, which should alleviate dribbling. The response "I know you're worried, but it will go away in a few days" identifies the feelings but does not actively help the client solve the problem. Limiting fluid intake and urinating at the urge do not increase bladder tone; the client should increase his fluid intake and gradually increase the time between voiding attempts. Continuous bladder decompression from a catheter will reduce bladder tone; bladder tone will improve after removal of the indwelling catheter.

Which statement about continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment? a. "Maintain a daily written record of blood pressure and weight." b. "It is essential that you maintain aseptic technique to prevent peritonitis." c. "You will be allowed a more liberal protein diet once you complete CAPD." d. "Continue regular medical and nursing follow-up visits while performing CAPD."

b. "It is essential that you maintain aseptic technique to prevent peritonitis." Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of prevention. Although the other teaching statements are accurate, they do not have the potential for morbidity and mortality that peritonitis does.

The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? a. "This is often due to an infection that will resolve on its own." b. "Many people experience an age-related decline in their hearing." c. "This is likely an effect of your medications. Try stopping them for a few days." d. "You can accommodate for your hearing loss with a few small changes in your routine."

b. "Many people experience an age-related decline in their hearing." Presbycusis is a loss of hearing that is both common and age-related. Infections are most often accompanied by different symptoms. It would be inappropriate to counsel the patient to stop his medications. It would be simplistic to advise the patient to accommodate the hearing loss rather than seek intervention.

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" Which initial response by the nurse is best? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."

b. "Tell me more about what you are thinking regarding dialysis." The nurse should initially clarify the patient's concerns and questions about dialysis. The patient is the one responsible for the decision, and many people using dialysis do have good quality of life, but these responses block further assessment of the patient's concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient's question.

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for a change in dosage of the eyedrops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eyedrops can be prescribed for you."

b. "The drops are uncomfortable, but it is important to use them to retain your vision." Patients should be taught that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use and do not indicate a need for a dosage or medication change.

The home care nurse visits a patient receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse? a. "Drain time is faster if I rub my abdomen." b. "The fluid draining from the catheter is cloudy." c. "The drainage is bloody when I have my period." d. "I wash around the catheter with soap and water."

b. "The fluid draining from the catheter is cloudy." The primary manifestation of peritonitis is a cloudy peritoneal effluent. Blood may be present in the effluent of women who are menstruating, and no intervention is indicated. Daily catheter care may include washing around the catheter with soap and water. Drain time may be facilitated by gently massaging the abdomen.

When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? a. "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." c. "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." d. "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."

b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time. Primary angle-closure glaucoma is caused by the lens bulging forward and blocking the flow of aqueous humor into the anterior chamber.

After a vasectomy, what instruction should be included in discharge teaching? a. "Some secondary sexual characteristics may be lost after the surgery." b. "Use an alternative form of contraception until your semen is sperm free." c. "Erectile dysfunction may be present for several months after this surgery." d. "You will be uncomfortable, but you may safely have sexual intercourse today."

b. "Use an alternative form of contraception until your semen is sperm free." Because vasectomies are usually done for sterilization purposes, to safely have sexual intercourse, the patient will need to use an alternative form of contraception until semen examination reveals no sperm. Hormones are not affected, so there is no loss of secondary sexual characteristics or erectile function. Most men experience too much pain to have sexual intercourse on the day of their surgery, so this is not an appropriate comment by the nurse.

A patient reports intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? a. "Do you use ginkgo to treat asthma symptoms?" b. "What do you take if you have allergy symptoms?" c. "Are you taking propranolol for anxiety disorder?" d. "Are you currently taking prednisone (Deltasone)?"

b. "What do you take if you have allergy symptoms?" Antihistamines or decongestants taken for allergies or colds can cause ocular dryness. Ginkgo biloba is an herbal product and has been used to treat asthma and tinnitus. Side effects of ginkgo may include headache, nausea, gastrointestinal upset, diarrhea, dizziness, allergic skin reactions, and increased bleeding. β-Adrenergic blockers can potentiate drugs used to treat glaucoma. Long-term use of prednisone (corticosteroids) may contribute to the development of glaucoma or cataracts.

Which information will the nurse provide to the patient scheduled for refractometry? a. "You should not take any of your eye medicines before the examination." b. "You will need to wear sunglasses for a few hours after the examination." c. "The doctor will shine a bright light into your eye during the examination." d. "The surface of your eye will be numb while the doctor does the examination."

b. "You will need to wear sunglasses for a few hours after the examination." The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

The nurse is teaching clinic patients about risk factors for testicular cancer. Which person is at highest risk for developing testicular cancer? a. A 48-yr-old black man with erectile dysfunction b. A 30-yr-old white man with a history of cryptorchidism c. A 19-yr-old Asian man who had surgery for testicular torsion d. A 28-yr-old Hispanic man with infertility caused by a varicocele

b. A 30-yr-old white man with a history of cryptorchidism The incidence of testicular cancer is four times higher in white men than in black men. Testicular tumors are also more common in men who have had undescended testes (cryptorchidism) or a family history of testicular cancer or anomalies. Other predisposing factors include orchitis, human immunodeficiency virus infection, maternal exposure to exogenous estrogen, and testicular cancer in the contralateral testis.

The nurse in a health clinic receives requests for appointments from several patients. Which patient should be seen by the health care provider first? a. A 48-yr-old patient who has perineal pain and a temperature of 100.4° F b. A 58-yr-old patient who has a painful erection that has lasted more than 6 hours c. A 38-yr-old patient who reports that he had difficulty maintaining an erection twice last week d. A 68-yr-old patient who has pink urine after a transurethral resection of the prostate (TURP) 3 days ago

b. A 58-yr-old patient who has a painful erection that has lasted more than 6 hours Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be treated immediately. The other patients do not require immediate action to prevent serious complications.

Which patient has the most significant risk factors for CKD? a. A 50-yr-old white woman with hypertension b. A 61-yr-old Native American man with diabetes c. A 28-yr-old black woman with a urinary tract infection d. A 40-yr-old Hispanic woman with cardiovascular disease

b. A 61-yr-old Native American man with diabetes The nurse identifies the 61-year-old Native American with diabetes as the most at risk. Diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD 6 times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. Blacks have the highest rate of CKD because hypertension is significantly increased in blacks. A UTI will not cause CKD unless it is not treated or UTIs occur recurrently.

Which patient is at highest risk for obstructive sleep apnea (OSA)? a. An 82-yr-old man with Parkinson's disease who has dysphagia. b. A 68-yr-old obese man who smokes one pack of cigarettes per day. c. An 18-yr-old woman with cystic fibrosis who has recurrent pneumonia. d. A 35-yr-old woman with a BMI of 22 kg/m2 who has seasonal allergies to pollen.

b. A 68-yr-old obese man who smokes one pack of cigarettes per day. Risk of OSA increases with obesity (BMI >30 kg/m2), age older than 65 years, neck circumference greater than 17 in, craniofacial abnormalities, and acromegaly. Smokers are more at risk for OSA, and OSA is more common in men than women (until menopause).

Which patient most clearly has signs and symptoms of primary insomnia? a. A patient in the habit of having a cappuccino in the late evening while watching TV. b. A patient whose increased sleep latency is not clearly attributable to any particular cause. c. A patient who has had frequent nighttime awakenings since the recent death of a spouse. d. A patient whose corticosteroid therapy causes him to feel "edgy" and unable to fall asleep at night.

b. A patient whose increased sleep latency is not clearly attributable to any particular cause. Insomnia that is not directly attributable to a cause is considered primary or idiopathic. The stimulants such as caffeine, prescription medications, or psychologic trauma result in secondary insomnia.

When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? a. Swimmer's ear b. Acute otitis media c. Impacted cerumen d. Chronic otitis media

b. Acute otitis media The inability to see the landmarks or light reflex of the tympanic membrane and the bulging and redness of the tympanic membrane are those of acute otitis media. With swimmer's ear and chronic otitis media, there is frequently drainage in the external auditory canal. Impacted cerumen would block the visualization of the tympanic membrane.

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid drops c. Need for bed rest for 1 to 2 days after the surgery d. Importance of coughing and deep breathing exercises

b. Administration of corticosteroid drops Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery, and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. Which would the nurse do initially? a. Encourage the client to exercise during the day. b. Arrange a referral for a thorough medical evaluation. c. Explain that this behavior is an attempt to avoid facing daily responsibilities. d. Identify that the client is describing clinical findings associated with narcolepsy.

b. Arrange a referral for a thorough medical evaluation. This behavior is a sign of hypersomnia, and the client needs a medical assessment; it is commonly caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia, and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing.

A 58-yr-old patient with erectile dysfunction (ED) tells the nurse he is interested in using sildenafil (Viagra). Which action should the nurse take first? a. Assure the patient that ED is common with aging. b. Ask the patient about any prescription drugs he is taking. c. Tell the patient that Viagra does not always work for ED. d. Discuss the common adverse effects of erectogenic drugs.

b. Ask the patient about any prescription drugs he is taking. Because some medications can cause ED and patients using nitrates should not take sildenafil, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of sildenafil therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease

A 75-yr-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Ask the patient about what type of vision problems are being experienced. c. Explain that there are many ways to compensate for decreases in visual acuity. d. Suggest ways of improving the patient's safety, such as using brighter lighting.

b. Ask the patient about what type of vision problems are being experienced. The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment.

A 27-yr-old patient who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is appropriate for the nurse to take? a. Teach the patient and the wife that impotence is unlikely after unilateral orchiectomy. b. Ask the patient if he has any questions or concerns about the diagnosis and treatment. c. Inform the patient's wife that concerns about sexual function are common with this diagnosis. d. Document the patient's lack of communication on the health record and continue preoperative care.

b. Ask the patient if he has any questions or concerns about the diagnosis and treatment. The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer teaching about complications after orchiectomy. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation.

A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks. What should the nurse include in the discharge teaching for this patient? a. Airplane travel will be more comfortable now. b. Avoid sudden head movements or position changes. c. Cough or blow the nose to keep the Eustachian tubes clear. d. Take antihistamines, antiemetics, and sedatives for recovery.

b. Avoid sudden head movements or position changes. After ear surgery, the patient should avoid sudden head movements or position changes. The patient should not cough or blow the nose because this increases pressure in the Eustachian tube and middle ear cavity and may disrupt healing. Airplane travel should be avoided at first as increased pressure and ear popping is normally experienced, which will disrupt healing. Antihistamines, antiemetics, and sedatives are used to decrease the symptoms of acute attacks of Ménière's disease.

During the health history interview, a 73-yr-old male patient states that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give anticipatory guidance about what condition? a. A tumor of the prostate b. Benign prostatic hyperplasia c. Bladder atony because of age d. Age-related altered innervation of the bladder

b. Benign prostatic hyperplasia Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men older than age 50 years and 80% of men older than age 80 years. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.

After reviewing the electronic medical record for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse? a. Elevated temperature and pulse b. Bladder spasms and urine output c. Respiratory rate and lung crackles d. No prescription for antihypertensive drugs

b. Bladder spasms and urine output Bladder spasms and lack of urine output indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need to manually irrigate the patient's catheter. The other information will also require actions, such as having the patient take deep breaths and cough and discussing the need for antihypertensive medication prescriptions with the health care provider, but the nurse's first action should be to address the problem with the urinary drainage system.

A patient with end-stage renal disease (ESRD) secondary to diabetes has arrived at the outpatient dialysis unit for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment? a. Level of consciousness b. Blood pressure and fluid balance c. Temperature, heart rate, and blood pressure d. Assessment for signs and symptoms of infection

b. Blood pressure and fluid balance Although all the assessments are relevant to the care of a patient receiving hemodialysis, fluid removal during the procedure will require monitoring blood pressure and fluid balance prior, during, and after.

What should the nurse assess to evaluate the effectiveness of treatment for the patient's myopia and presbyopia? a. Strength of the eye muscles. b. Both near and distant vision. c. Cloudiness in the eye lenses. d. Intraocular pressure changes.

b. Both near and distant vision. Lenses are prescribed to correct the patient's near and distant vision. The nurse may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient's bifocals are effective.

Which action could the registered nurse (RN) who is working in the clinic delegate to a licensed practical/vocational nurse (LPN/VN)? a. Evaluate a patient's ability to administer eyedrops. b. Check a patient's visual acuity using a Snellen chart. c. Inspect a patient's external ear for signs of irritation caused by a hearing aid. d. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D.

b. Check a patient's visual acuity using a Snellen chart. Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice.

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

b. Check blood pressure before starting dialysis. Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check the blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

b. Check the blood pressure (BP). The patient's reports of nausea and dizziness suggest hypotension, so the first action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.

The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. Which action by the student indicates that the nurse should intervene? a. Pulls the auricle of the ear up and posterior. b. Chooses a speculum larger than the ear canal. c. Stabilizes the hand holding the otoscope on the patient's head. d. Stops inserting the otoscope after observing impacted cerumen.

b. Chooses a speculum larger than the ear canal. The speculum should be smaller than the ear canal, so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

What should the nurse teach a patient with repeated hordeolum about how to prevent further infection? a. Apply cold compresses. b. Discard all used eye cosmetics. c. Wash the eyebrows with an antiseborrheic shampoo. d. Be examined for sexually transmitted infections (STIs).

b. Discard all used eye cosmetics. Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STI testing.

The nurse is caring for a patient diagnosed with adult inclusion conjunctivitis (AIC) caused by C. trachomatis. Which action should be included in the plan of care? a. Applying topical corticosteroids to decrease inflammation b. Discussing the need for sexually transmitted infection testing c. Educating about the use of antiviral eyedrops to treat the infection d. Assisting with applying for community visual rehabilitation services

b. Discussing the need for sexually transmitted infection testing Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate.

What will the nurse plan to teach the patient who is incontinent of urine following a radical retropubic prostatectomy? a. Restrict oral fluid intake. b. Do pelvic muscle exercises. c. Perform intermittent self-catheterization. d. Use belladonna and opium suppositories.

b. Do pelvic muscle exercises. Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L.

A patient with type 2 diabetes and chronic kidney disease has a serum potassium level of 6.8 mEq/L. Which finding will the nurse monitor for? a. Fatigue b. Dysrhythmias c. Hypoglycemia d. Elevated triglycerides

b. Dysrhythmias Hyperkalemia is the most serious electrolyte disorder associated with kidney disease. Fatal dysrhythmias can occur when the serum potassium level reaches 7 to 8 mEq/L. Fatigue and hypertriglyceridemia may be present but do not require urgent intervention. Hypoglycemia is a complication related to diabetes control, not hyperkalemia. However, administration of insulin and dextrose is an emergency treatment for hyperkalemia.

A patient donated a kidney via a laparoscopic donor nephrectomy to a nonrelated recipient. The patient is having significant pain and refuses to get up to walk. How should the nurse respond? a. Allow the patient to rest and try again tomorrow. b. Encourage a short walk around the patient's room. c. Have the transplant psychologist convince her to walk. d. Tell the patient she is lucky she did not have an open nephrectomy.

b. Encourage a short walk around the patient's room. Because ambulating will improve bowel, lung, and kidney function with improved circulation, even a short walk with assistance should be encouraged after pain medication. The transplant psychologist or social worker's role is to determine if the patient is emotionally stable enough to handle donating a kidney; postoperative care is the nurse's role. Telling the patient she is lucky she did not have an open nephrectomy (implying how much more pain she would be having if it had been open) will not be beneficial to the patient or her postoperative recovery. Early ambulation should be encouraged, waiting until tomorrow is too long.

When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? a. Giving anticipatory guidance about the loss of central vision that will occur b. Encouraging compliance with drug therapy for the glaucoma to prevent vision loss c. Recognizing that eye damage caused by glaucoma can be reversed in the early stages d. Managing the pain patients with glaucoma have that persists until the optic nerve atrophies

b. Encouraging compliance with drug therapy for the glaucoma to prevent vision loss Drug therapy is necessary to prevent the eventual vision loss that may occur as a consequence of glaucoma. For this reason, encourage the patient to remain compliant with drug therapy.

After an acoustic neuroma is removed from a patient, the nurse teaches the patient about tumor recurrence. What should the nurse instruct the patient to monitor? (Select all that apply.) a. Lack of coordination b. Episodes of dizziness c. Worsening of hearing d. Inability to close the eye e. Clear drainage from the nose

b. Episodes of dizziness c. Worsening of hearing An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal. Clinical manifestations of tumor recurrence including facial nerve (CN VII) paralysis can be manifested by intermittent vertigo, hearing loss, and inability to close the eye. Lack of coordination and clear nasal drainage do not manifest with acoustic neuroma.

A patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Keep the volume low on the hearing aids for the first week. b. Experiment with volume and hearing in a quiet environment. c. Add the second hearing aid after making adjustments to the first hearing aid. d. Begin wearing the hearing aids for an hour a day, gradually increasing the use.

b. Experiment with volume and hearing in a quiet environment. Initially the patient should use the hearing aids in a quiet environment such as the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

b. Fill the irrigation syringe with body-temperature solution. Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe.

The occupational health nurse is caring for an employee who reporting bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take? a. Apply cool compresses. b. Flush the eyes with saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

b. Flush the eyes with saline. In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available. No other interventions should delay flushing the eyes.

Which action to promote sleep would the nurse recommend to a client? a. Having a snack in bed before trying to sleep b. Getting out of bed if unable to fall asleep after 20 minutes c. Performing vigorous exercise an hour before bedtime d. Raising the temperature of the bedroom

b. Getting out of bed if unable to fall asleep after 20 minutes To prevent sleep disturbances, a client should get out of bed if he or she is not able to fall asleep after 20 minutes. To prevent sleep disturbances, a client should not perform strenuous exercise within 6 hours before bedtime. A client should avoid reading, writing, and eating in bed. The client should also lower the temperature of the bedroom and keep it dark and quiet.

The patient tells the nurse that it is much easier to read books on the tablet computer after applying a matte screen protector. Which is the best explanation for this? a. Glare causes headaches. b. Glare reduces visual acuity. c. Bright light overstimulates the retina. d. Too much light damages the iris.

b. Glare reduces visual acuity. When a patient ages, the pupil loses the ability to adjust to bright light. An antiglare screen protector therefore makes it easier for the patient to read text on the tablet computer. While glare can cause headaches for some people, it does not explain why the patient has an easier time reading text on the computer after the antiglare screen protector is applied. Overly bright light does not cause overstimulation of the retina or damage to the iris.

When caring for patients with sleep disorders, which activity can the nurse appropriately delegate to unlicensed assistive personnel (UAP)? a. Assist a patient to choose a new CPAP mask. b. Help a patient to put on the CPAP device at bedtime. c. Interview a patient about risk factors for obstructive sleep disorders. d. Discuss the benefits of oral appliances in decreasing obstructive sleep apnea.

b. Help a patient to put on the CPAP device at bedtime. Because a CPAP mask is worn consistently in the same way and will have been previously fitted by a licensed health professional, a UAP can assist the patient with putting the mask on. The other actions require critical thinking and nursing judgment by the RN.

The health care provider prescribes finasteride (Proscar) for a patient who has benign prostatic hyperplasia (BPH). What information should the nurse provide when teaching the patient about the drug? a. He should change position from lying to standing slowly to avoid dizziness. b. His interest in sexual activity may decrease while he is taking the medication. c. Improvement in the obstructive symptoms should occur within about 2 weeks. d. He will need to monitor his blood pressure frequently to assess for hypertension.

b. His interest in sexual activity may decrease while he is taking the medication. A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Although orthostatic hypotension may occur if the patient is also taking a medication for erectile dysfunction, it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension.

Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. Which strategy is used to achieve ultrafiltration in peritoneal dialysis? a. Increasing the pressure gradient b. Increasing osmolality of the dialysate c. Decreasing the glucose in the dialysate d. Decreasing the concentration of the dialysate

b. Increasing osmolality of the dialysate Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis, the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream.

A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first? a. Infuse normal saline at 50 mL/hr. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Schedule pelvic magnetic resonance imaging

b. Insert a urinary retention catheter. The patient data indicate that the patient may have acute kidney injury caused by the BPH. The initial therapy will be to insert a catheter. The other actions are also appropriate, but they can be implemented after the acute urinary retention is resolved.

Which action would the nurse take first for a client who just had a transurethral resection of the prostate and reports pain in the operative area? a. Administer the prescribed analgesic b. Inspect the drainage tubing for patency c. Encourage intake of fluids to dilute urine d. Take a full set of vital signs

b. Inspect the drainage tubing for patency Pain after a prostatectomy may indicate retention of urine as a result of blocked drainage tubes or infection, or it may be an expected response to surgery. The possibility of any complication must be investigated. Analgesics can be administered after the cause of pain is investigated. Encouraging fluids without a patent drainage tube will increase pressure and discomfort; assessment should occur before implementation. The need to measure vital signs is dependent upon the analgesic prescribed; assessing the cause of pain takes priority.

The nurse cares for an unstable patient in the intensive care unit (ICU). Which intervention should the nurse include in the plan of care to improve this patient's sleep quality? a. Ask all visitors to leave the hospital for the night. b. Lower the level of lighting from 8:00 PM until 7:00 AM. c. Avoid the use of opioids for pain relief during the evening. d. Schedule assessments to allow 4 hours of uninterrupted sleep.

b. Lower the level of lighting from 8:00 PM until 7:00 AM. Lowering the level of light will help mimic normal day/night patterns and maximize the opportunity for sleep. Although frequent assessments and opioid use can disturb sleep patterns, these actions are necessary for the care of unstable patients. For some patients, having a family member or friend at the bedside may decrease anxiety and improve sleep.

The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan? a. Augmenting fluid volume b. Maintaining cardiac output c. Diluting nephrotoxic substances d. Preventing systemic hypertension

b. Maintaining cardiac output The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses could be correct.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

b. Mannitol (Osmitrol) 100 mg IV The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered.

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

b. More protein is allowed because urea and creatinine are removed by dialysis. When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Glucose is not lost during hemodialysis. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

The nurse is assessing a client who reports excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep. Which disorder would the nurse suspect that the client is experiencing? a. Nocturia b. Narcolepsy c. Sleep apnea d. Sleep deprivation

b. Narcolepsy Narcolepsy is a neurological disorder that results in irregular sleep and wake states. A client with narcolepsy may experience problems such as excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep. Nocturia is urination at night that interrupts the sleep and wake cycle. Sleep apnea is the absence of airflow through the nose and moth for periods of 10 seconds or more during sleep. Sleep deprivation can cause fever, difficulty breathing, and pain, among other things.

A client reports overwhelming and irresistible attacks of sleep. Which sleep disorder is she or he describing? a. Insomnia b. Narcolepsy c. Sleep terror d. Sleep apnea

b. Narcolepsy Narcolepsy is overwhelming sleepiness that results in irresistible attacks of sleep, loss of muscle tone (cataplexy), and hallucinations or sleep paralysis at the beginning or end of sleep episodes; the person usually awakens from the sleep feeling refreshed. Insomnia is difficulty initiating or maintaining sleep. Sleep terrors are recurrent episodes of abrupt awakening from sleep accompanied by intense fear, screaming, tachycardia, tachypnea, and diaphoresis with no detailed dream recall. Sleep apnea is a breathing-related sleep disorder caused by disrupted respirations or airway obstruction; sleep is disrupted numerous times throughout the night.

How should the nurse evaluate a patient for improvement after treatment of primary open-angle glaucoma (POAG)? a. Question the patient about blurred vision. b. Note any changes in the patient's visual field. c. Ask the patient to rate the pain using a 0 to 10 scale. d. Assess the patient's depth perception when climbing stairs.

b. Note any changes in the patient's visual field. POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a. The patient reports ear "fullness." b. Oral temperature is 100.8° F (38.1° C). c. Small amount of dried drainage on dressing. d. The patient reports that hearing has gotten worse

b. Oral temperature is 100.8° F (38.1° C). An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery.

Which patient arriving at the urgent care center will the nurse assess first? a. Patient who is reporting that the left eyelid has just started to droop b. Patient with acute right eye pain that began while using power tools c. Patient with purulent left eye discharge and conjunctival inflammation d. Patient who has redness, crusting, and swelling along the lower right lid margin

b. Patient with acute right eye pain that began while using power tools The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss.

Which action can the nurse working in the emergency department delegate to an experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.

b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN.

A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? a. Photorefractive keratectomy (PRK) b. Phakic intraocular lenses (phakic IOLs) c. Refractive intraocular lens (refractive IOL) d. Laser-assisted in situ keratomileusis

b. Phakic intraocular lenses (phakic IOLs) Phakic intraocular lenses (phakic IOLs) is the implantation of a contact lens in front of the natural lens. PRK is used with low to moderate amounts of myopia, and the epithelium is removed and the laser sculpts the cornea to correct the refractive error. Refractive IOL is also for patients with a high degree of myopia or hyperopia and involves removing the natural lens and implanting an intraocular lens. LASIK surgery is similar to PRK except that the epithelium is replaced after surgery.

Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

b. Phosphate level Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient.

b. Place a fall-risk bracelet on the patient. Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Poached eggs, whole-wheat toast, and apple juice c. Oatmeal with cream, half a banana, and herbal tea d. Cheese sandwich, tomato soup, and cranberry juice

b. Poached eggs, whole-wheat toast, and apple juice Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate.

What laboratory value should the nurse check before administering captopril to a patient with stage 2 chronic kidney disease? a. Glucose b. Potassium c. Creatinine d. Phosphate

b. Potassium Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect whether the captopril was given or not.

Which action should the nurse manager promote as an evidence-based practice to support alertness for night shift nurses? a. Arrange for older staff members to work most night shifts. b. Provide a sleeping area for staff to use for napping at night. c. Post reminders about the relationship of sleep and alertness. d. Schedule nursing staff to rotate day and night shifts monthly.

b. Provide a sleeping area for staff to use for napping at night. Short onsite naps will improve alertness. Rotating shifts causes the most disruption in sleep habits. Reminding staff members about the impact of lack of sleep on alertness will not improve sleep or alertness. It is not feasible to schedule nurses based on their ages.

Which initial action would the nurse take for a newly admitted client who reports memory loss, nervousness, insomnia, and fear of leaving the house? a. Evaluate the client's adjustment to the unit. b. Provide the client with a sense of security and safety. c. Explore the client's memory loss and fear of going out. d. Assess the client's perception of reasons for the hospitalization.

b. Provide the client with a sense of security and safety. The initial action is to provide the client with a sense of security and safety. The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. It is too early to evaluate the client's adjustment to the unit. Additionally, if the client is not provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.

Which bedtime action by the nurse may make it more difficult for the patient to fall asleep? a. Giving the patient a gentle backrub b. Providing a warm cup of hot chocolate c. Encouraging the patient to use the bathroom d. Giving the patient an extra blanket when cold

b. Providing a warm cup of hot chocolate Coffee, tea, cola, and chocolate cause a person to stay awake or awaken throughout the night. Promote comfort by encouraging the patient to wear loose-fitting nightwear, void before bedtime, give a relaxing backrub, and offer an extra blanket to prevent chilling when trying to fall asleep.

What is the first action the nurse should take in addressing a patient's concerns about insomnia and daytime fatigue? a. Suggest that the patient decrease caffeine intake. b. Question the patient about sleep and rest patterns. c. Recommend to use any prescribed sleep aids for no more than 2 weeks. d. Advise the patient to get out of bed if unable to fall asleep in 20 minutes

b. Question the patient about sleep and rest patterns. The nurse's first action should be assessment of the patient related to current sleep and rest. The other actions may be appropriate, but assessment is needed first to choose appropriate interventions to improve the patient's sleep.

Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30? a. Persistent skin tenting b. Rapid, deep respirations c. Hot, flushed face and neck d. Bounding peripheral pulses

b. Rapid, deep respirations Patients with metabolic acidosis caused by AKI may have Kussmaul respirations to eliminate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

What should the nurse teach the patient before fluorescein angiography? a. Hold a card and fixate on the center dot. b. Report any burning or pain at the IV site. c. Remain still while the cornea is anesthetized. d. Let the examiner know when images shown appear clear.

b. Report any burning or pain at the IV site. Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. Teach the patient to report any signs of extravasation, such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand-held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take? a. Remind the patient to take a daily low-dose aspirin tablet. b. Report the patient's symptoms to the health care provider. c. Elevate the patient's arm on pillows above the heart level. d. Teach the patient about normal arteriovenous graft function.

b. Report the patient's symptoms to the health care provider. The patient's problems suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevating the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

The nurse is caring for a patient who is in the oliguric phase of acute kidney disease. Which action would be appropriate to include in the plan of care? a. Provide foods high in potassium. b. Restrict fluids based on urine output. c. Monitor output from peritoneal dialysis. d. Offer high-protein snacks between meals.

b. Restrict fluids based on urine output. Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.

Which is the priority nursing diagnosis for an adolescent who gets up at 5:00 a.m. every morning for school and studies until midnight every night? a. Fatigue related to insufficient rest and stress of academic demands b. Risk for injury related to inattention and excessive daytime sleepiness c. Deficient diversional activity related to lack of time for recreation and leisure d. Impaired social interaction related to time required to study and maintain grades

b. Risk for injury related to inattention and excessive daytime sleepiness Adolescents need between 8 to 10 hours of sleep each night. An adolescent who gets only 5 hours of sleep at night is at risk of injury due to intention and effects of excessive daytime sleepiness. This is particularly true if the adolescent is driving. Fatigue, deficient diversional activity, and impaired social interaction are all less important than the risk for injury.

A patient tells the nurse that he decided to seek treatment for erectile dysfunction (ED) because his partner "is losing patience with the situation." Which patient concern should be the focus of the nurse's follow-up questions? a. Low self-esteem b. Role performance c. Increased anxiety. d. Infrequent intercourse.

b. Role performance The patient's statement indicates that the relationship with his partner is his primary concern. Although anxiety, low self-esteem, and ineffective sexuality patterns may also be concerns, the patient information suggests that addressing the role performance problem will lead to the best outcome for this patient.

A patient reports dizziness when bending over and of nausea and dizziness associated with physical activities. What exam should the nurse expect to prepare the patient to undergo? a. Tympanometry b. Rotary chair testing c. Pure-tone audiometry d. Bone-conduction testing

b. Rotary chair testing The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

A patient tells the nurse that she is having trouble falling asleep and staying asleep. Which studies does the nurse anticipate teaching the patient about? a. EEG b. Self-report c. Actigraphy d. Polysomnography

b. Self-report The diagnosis of insomnia is based on self-report of difficulty falling or remaining asleep. EEG is used with polysomnography sleep studies to diagnose other sleep disorders. Actigraphy measures gross motor activity.

Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. Unequal pupil size b. Sensitivity to light c. Loss of peripheral vision d. History of hyperthyroidism

b. Sensitivity to light Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts. Loss of peripheral vision is a sign of glaucoma.

Which laboratory result should the nurse check before administering calcium carbonate to a patient with chronic kidney disease? a. Serum potassium b. Serum phosphate c. Serum creatinine d. Serum cholesterol

b. Serum phosphate If serum phosphate is increased, the calcium and phosphate can cause soft tissue calcification. Calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

A 25-yr-old patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? a. Serum creatinine level of 2.1 mg/dL b. Serum potassium level of 6.5 mEq/L c. White blood cell count of 11,500/µL d. Blood urea nitrogen (BUN) of 56 mg/dL

b. Serum potassium level of 6.5 mEq/L treated immediately. The nurse will report the other laboratory values, but abnormalities in these are not immediately life threatening.

A nurse is caring for a patient who signs and lip reads. When communicating, the most appropriate nursing action is to do which of the following? a. Rely on friends or family members to interpret for the patient. b. Sit facing the patient when speaking and ensure there is adequate light. c. Repeat the entire conversation if it is not clearly understood the first time. d. Speak louder and more distinctly than normal with exaggerated lip movements.

b. Sit facing the patient when speaking and ensure there is adequate light. Nurses can use a variety of communication techniques, including reading notes and writing notes, as well as reading lips and signing. When communicating, nurses should speak slowly and articulate clearly. The nurse should be seated facing the patient and ensure that there is enough light for the patient to see the nurse's lips clearly. When you are not understood, rephrase rather than repeating the entire conversation. Some patients with hearing impairments are able to speak normally. To more clearly hear what a person communicates, family and friends need to learn to move away from background noise, rephrase rather than repeat sentences, be positive, and have patience. On the other hand, some deaf patients have serious speech alterations.

Which priority teaching intervention would the nurse include in the care plan for a client who has insomnia? a. Medication administration procedures b. Sleep and cognitive changes c. Dietary measures to be followed at night d. Nonpharmacological measures, including sleep techniques

b. Sleep and cognitive changes The nurse would first teach about sleep and cognitive changes to the client with insomnia. The nurse can teach about medication administration procedures, but this is not the priority. The nurse can teach dietary measures to be follows at night after teaching about sleep and behavioral changes. Teaching about nonpharmacological procedures is also not the priority nursing intervention.

The nurse is preparing a patient to have a sleep study to determine if sleep apnea is present. What should the nurse teach the patient to do until the test can be completed? a. Take sleep medications. b. Sleep in a side-lying position. c. Use the spouse's CPAP mask. d. Do not use pillows when sleeping.

b. Sleep in a side-lying position. Conservative treatment for mild obstructive sleep apnea (OSA) begins with sleeping on one's side. Sleep medication often makes OSA worse. CPAP is adjusted for the patient and used with more severe symptoms after diagnosis. Elevating the head of the bed may eliminate OSA.

When examining the patient's ear with an otoscope, the nurse observes discharge in the canal and the patient reports pain with the examination. What should the nurse next assess the patient for? a. Sebaceous cyst b. Swimmer's ear c. Metabolic disorder d. Serous otitis media

b. Swimmer's ear Swimmer's ear or an infection of the external ear is probably the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. After clearing the discharge, the tympanic membrane can be assessed for otitis media. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal.

A patient with sleep apnea who uses a continuous positive airway pressure (CPAP) device is preparing to have inpatient surgery. Which instructions should the nurse provide to the patient? a. Schedule a preoperative sleep study. b. Take your home device to the hospital. c. Expect intubation with mechanical ventilation after surgery. d. Avoid requesting pain medication while you are hospitalized.

b. Take your home device to the hospital. The patient should be told to take the CPAP device to the hospital if an overnight stay is expected. Many patients will be able to use their own CPAP equipment. Patients should be treated for pain and monitored for respiratory depression. Another sleep study is not required before surgery. A person with sleep apnea would not routinely be expected to require postoperative intubation and mechanical ventilation.

What should the nurse include when teaching a patient who has undergone a left tympanoplasty? a. "Remain on bed rest." b. "Keep your head elevated." c. "Avoid blowing your nose." d. "Irrigate your left ear canal."

c. "Avoid blowing your nose." Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

Which information will the nurse plan to include when teaching a young adult who has a family history of testicular cancer about testicular self-examination? a. Testicular self-examination should be done at least weekly. b. Testicular self-examination should be done in a warm room. c. The only structure normally felt in the scrotal sac is the testis. d. Call the health care provider if one testis is larger than the other.

b. Testicular self-examination should be done in a warm room. The testes will hang lower in the scrotum when the temperature is warm (e.g., during a shower), and it will be easier to palpate. The epididymis is also normally palpable in the scrotum. One testis is normally larger. Men at high risk should perform testicular self-examination monthly.

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which action requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

b. The nurse encourages the patient to cough. Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with human immunodeficiency virus.

b. The patient has metastatic lung cancer. Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

The nurse is performing an eye examination on a 76-yr-old patient. Which finding indicates that the nurse should refer the patient for a more extensive assessment? a. The patient's sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

b. The patient reports persistent photophobia. Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences in assessment and would not be unusual in a 76-yr-old patient.

An obese patient is scheduled to begin treatment with continuous positive airway pressure (CPAP). When developing the plan of care, what outcome would be appropriate for this patient? a. The patient will be calm. b. The patient will have no airway collapse. c. The patient will have increased gas exchange. d. The patient will breathe through the nose rather than mouth.

b. The patient will have no airway collapse. CPAP maintains sufficient positive pressure (5 to 25 cm H2O) in the airway during inspiration and expiration to prevent airway collapse. CPAP does not exclusively require the patient to breathe through his or her nose.

Which outcome is most appropriate for the patient with the nursing diagnosis insomnia related to night shift work? a. The patient will rotate day/night work shifts frequently. b. The patient will obtain at least 48 hours of sleep per week. c. The patient will use caffeine sparingly to wake up before shifts. d. The patient will use bright lights to stay awake through the night.

b. The patient will obtain at least 48 hours of sleep per week. The patient should obtain at least 48 hours of sleep per week, during the day and night as shifts permit. Frequent rotation of night/day shifts will worsen insomnia. Use of bright lights and caffeine are interventions rather than goals.

Which is the most appropriate goal for a patient with the nursing diagnosis risk for loneliness related to loss of spouse and admission to long-term nursing facility? a. The patient will use effective coping strategies to prevent self-harm. b. The patient will participate in at least one group activity every week. c. The patient will assist staff with activities of daily living every morning. d. The patient will express the desire to achieve increased levels of comfort.

b. The patient will participate in at least one group activity every week. The appropriate goal for a patient at risk of loneliness is for the patient to participate in at least one group activity every week. This will allow the patient to meet other residents and hopefully develop some friendships. The prevention of self-harm, assisting with activities of daily living, and desiring increased comfort are not appropriate goals for risk of loneliness.

Which nursing intervention can cause an unsafe sleeping environment for the hospitalized patient? a. A small night-light left on in the bedroom. b. The patient's bed is in high position with side rails up. c. All clutter is removed between the bed and the bathroom. d. Call bell at the bedside for the patient to contact the nurse.

b. The patient's bed is in high position with side rails up. A bed in high position with side rails up is a safety hazard. Safety precautions are important for patients who awaken during the night to use the bathroom and for those with excessive daytime sleepiness. Set beds lower to the floor to lessen the chance of the patient falling when first standing. Remove clutter, and move equipment from the path a patient uses to walk from the bed to the bathroom. If patient needs assistance in ambulating from the bed to the bathroom, make sure the call light is within the patient's reach. The call light helps alert the nursing staff, not the family. A small night-light is beneficial to help with vision.

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient reports level 7 (0- to 10-point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

b. The patient's central venous pressure (CVP) is decreased. The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

The nurse is obtaining the pertinent health history for a man who is being evaluated for infertility. Which question focuses on a possible cause of infertility? a. "Are you circumcised?" b. "Have you had surgery for phimosis?" c. "Do you use medications to improve muscle mass?" d. "Is there a history of prostate cancer in your family?"

c. "Do you use medications to improve muscle mass?" Testosterone or testosterone-like medications may adversely affect sperm count. The other information will be obtained in the health history but does not affect the patient's fertility.

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient's abdomen appears bloated after the inflow. d. The patient has abdominal pain during the inflow phase.

b. The patient's peritoneal effluent appears cloudy. Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

Which equipment does the nurse need to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

b. Tuning fork Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.

The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates improvement of the middle ear infection? a. Fenestrations are visible in the tympanic membrane. b. Tympanic membrane is gray, shiny, and translucent. c. Cone of light is not visible on the tympanic membrane. d. Tympanic membrane is blue and bulging with no landmarks.

b. Tympanic membrane is gray, shiny, and translucent. The tympanic membrane (TM) is normally pearly gray, white or pink, shiny, and translucent. Perforation of the TM that has not healed will appear as open areas of the tympanic membrane. The absence of the cone of light indicates a retracted TM. A bulging red or blue eardrum and lack of landmarks indicates a fluid-filled middle ear. The fluid may be pus or blood.

Unlicensed assistive personnel (UAP) perform the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene? a. UAP raises the side rails on the bed. b. UAP turns on the patient's television. c. UAP places an emesis basin at the bedside. d. UAP helps the patient turn to the right side.

b. UAP turns on the patient's television. Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack.

The nurse is caring for a patient who has a severe right-sided stroke with left-sided hemiplegia. The patient uses the right extremities well but does not realize that the left arm and leg even exist. Which is the most appropriate nursing diagnosis for this patient? a. Deficient knowledge related to presence of paralyzed left arm and leg b. Unilateral neglect related to brain tissue damage after right-sided stroke c. Ineffective denial related to inability to accept paralysis of left arm and leg d. Noncompliance related to inability to follow directions to use left arm and leg

b. Unilateral neglect related to brain tissue damage after right-sided stroke Unilateral neglect occurs when the patient is unaware that a body area exists after a neurological injury or stroke. This patient demonstrates unilateral neglect by not realizing that the left arm and leg exist. Knowledge deficit, noncompliance, and ineffective denial do not explain the patient's lack of realization of the left-sided extremities.

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

b. Urine output Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is less than 30 mL/min/1.73 m2.

b. Urine output over an 8-hour period is 2500 mL. The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

A patient informs the nurse that he is working the night shift and has difficulty sleeping during the day. What suggestions can the nurse offer to assist him with sleeping in the daylight hours? a. Make the bedroom warmer. b. Use room-darkening window shades. c. Drink warm tea at the end of the shift. d. Go to the gym to work out before going home to sleep.

b. Use room-darkening window shades. Light is the strongest time cue for the sleep-wake rhythm. Darkening the room will help the hypothalamus to adjust to this change in sleep pattern. Measures to facilitate sleep include a quiet and cool room, no caffeine intake 4 to 6 hours before bedtime, and avoiding exercise 6 hours before bedtime. Scheduling sleep and waking time to just before going to work may also increase alertness and vigilance at work.

Which nursing intervention is the highest priority when caring for an impulsive, forgetful stroke patient with right-sided paralysis? a. Complete a fall risk assessment such as the Hendrich II Fall Risk Model. b. Utilize a bed alarm and respond immediately when it is triggered. c. Place the call light within easy reach and remind the patient to use it. d. Apply a soft restraint to the patient's left wrist to prevent getting out of bed.

b. Utilize a bed alarm and respond immediately when it is triggered. The nurse should utilize a bed alarm for the patient and respond immediately when it is triggered indicating that the patient is starting to get up. This way the nurse will be able to intervene before the patient is able to get out of the bed. The patient is already known to be a fall risk so completing an additional fall risk assessment is unnecessary. The patient is forgetful and likely will not remember to use the call light. Restraints should be used only as a last result as they can cause significant injury and distress to the patient.

What should the nurse assess for when performing a focused examination to determine possible causes of infertility? a. Hydrocele b. Varicocele c. Epididymitis d. Paraphimosis

b. Varicocele Persistent varicoceles are commonly associated with infertility. Hydrocele, epididymitis, and paraphimosis are not risk factors for infertility.

A patient diagnosed with narcolepsy wants to know what can be done to cure it. What is the best response the nurse can give this patient? a. "If you take your medicine and naps, you will be cured." b. "Patient support groups may be able to help you feel better." c. "Drug therapy and behavioral strategies will be used to help treat it." d. "Safety precautions must only be when you are driving an automobile."

c. "Drug therapy and behavioral strategies will be used to help treat it." Narcolepsy cannot be cured. Measures to treat narcolepsy include drug therapy for promoting wakefulness during the day, sleep hygiene measures, and other behavioral strategies to enhance nighttime sleep. A patient support group may help the patient feel better, but it will not cure narcolepsy. Safety precautions are needed with driving, but also with other activities as falling asleep or losing muscle control can transform actions that are ordinarily safe (e.g., walking down a long flight of stairs) into hazards.

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

c. "Have you noticed ringing in your ears?" Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

The nurse is preparing to administer timolol eyedrops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? a. "I have sinusitis." b. "I have migraine headaches a lot." c. "I have chronic obstructive pulmonary disease." d. "I have a history of chronic urinary tract infections."

c. "I have chronic obstructive pulmonary disease." Timolol is a nonselective β-adrenergic blocker that could lead to bronchoconstriction and bronchospasm. For this reason, it should not be used in patients with COPD. Timolol may be used to treat migraine headaches, and it does not affect sinusitis or chronic urinary tract infections.

The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? a. "I doubt my other eye will ever be affected." b. "I can expect severe pain after this procedure." c. "I should avoid lifting heavy objects and straining." d. "The procedure will correct my vision immediately."

c. "I should avoid lifting heavy objects and straining." Patients should avoid heavy lifting (more than 20 lb) and straining. A patient with a detached retina is at risk for detachment of the other retina. Patients usually have little to no discomfort after scleral buckling. Severe, persistent pain should be reported immediately to the health care provider. Vision is restored in about 90% of retinal detachments. Vision will not be restored immediately and takes days to weeks to improve.

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."

c. "I will clean the ear canal daily with a cotton-tipped applicator." Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful.

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my output each day to help calculate the amount I can drink." d. "I need erythropoietin injections to boost my immunity and prevent infection."

c. "I will measure my output each day to help calculate the amount I can drink." The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

Which statement by the patient to the home health nurse indicates a need for further teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I will hold the tip of the dropper above the ear to administer the drops." c. "I will refrigerate the medication until I am ready to administer the drops." d. "I should lie down before and for 5 minutes after administering the drops."

c. "I will refrigerate the medication until I am ready to administer the drops." Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate.

Which information regarding a patient's sleep is most important for the nurse to communicate to the health care provider? a. A 21-yr-old student who takes melatonin to assist in sleeping when traveling from the United States to Europe b. A 64-yr-old nurse who works the night shift reports drinking hot chocolate before going to bed in the morning c. A 41-yr-old librarian who has a body mass index (BMI) of 42 kg/m2 says that the spouse complains about snoring d. A 32-yr-old accountant who is experiencing a stressful week uses diphenhydramine (Benadryl) for several nights

c. A 41-yr-old librarian who has a body mass index (BMI) of 42 kg/m2 says that the spouse complains about snoring The patient's BMI and snoring suggest possible sleep apnea, which can cause complications such as dysrhythmias, hypertension, and right-sided heart failure. Melatonin is safe to use as a therapy for jet lag. Short-term use of diphenhydramine in young adults is not a concern. Hot chocolate contains only 5 mg of caffeine and is unlikely to affect this patient's sleep quality.

The nurse in the clinic notes elevated prostate-specific antigen (PSA) levels in the laboratory results of these patients. Which patient's elevated PSA result requires further evaluation? a. A 38-yr-old patient who is being treated for acute prostatitis b. A 52-yr-old patient who goes on long bicycle rides every weekend c. A 48-yr-old patient whose father died of metastatic prostate cancer d. A 75-yr-old patient who uses saw palmetto to treat benign prostatic hyperplasia (BPH)

c. A 48-yr-old patient whose father died of metastatic prostate cancer The family history of prostate cancer and elevation of PSA indicate that further evaluation of the patient for prostate cancer is needed. Elevations in PSA for the other patients are not unusual.

Which assessment finding should the nurse report to the health care provider? a. Visible cone of light b. Dry skin in the ear canal c. A blue-tinged tympanum d. Cerumen in the auditory canal

c. A blue-tinged tympanum A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

A patient who had a kidney transplant eight years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone. Which assessment data will be of most concern to the nurse? a. Skin is thin and fragile. b. Blood pressure is 150/92. c. A nontender axillary lump. d. Blood glucose is 144 mg/dL

c. A nontender axillary lump. A nontender lump suggests a secondary cancer, such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The increased glucose, skin change, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of cancer.

The nurse providing care to a group of patients during the night sets a goal of promoting restful sleep. How would the nurse best define sleep? a. An unconscious state in which arousal is not easily accomplished. b. A basic but unorganized behavior that is not necessary for survival. c. A state during which a person lacks conscious awareness but can easily be aroused. d. A state of chemical balance among acetylcholine, norepinephrine, and serotonin.

c. A state during which a person lacks conscious awareness but can easily be aroused. Sleep is a state during which a person lacks conscious awareness of environmental surroundings and from which one can be easily aroused. Sleep is a basic, highly organized behavior.

The nurse coordinates postoperative care for a 70-year-old man with osteoarthritis after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Teach the patient how to perform Kegel exercises. b. Provide instructions to the patient on catheter care. c. Administer oxybutynin (Ditropan) for bladder spasms. d. Manually irrigate the urinary catheter to restore catheter flow. e. Monitor catheter drainage for clots and increase flow of irrigation as needed.

c. Administer oxybutynin (Ditropan) for bladder spasms. d. Manually irrigate the urinary catheter to restore catheter flow. e. Monitor catheter drainage for clots and increase flow of irrigation as needed. The nurse may delegate the following to an LPN/VN: monitor catheter drainage for increased blood or clots, increase flow of irrigating solution to maintain light pink color in outflow, and administer antispasmodics and analgesics as needed. A registered nurse may not delegate teaching, assessments, or clinical judgments to the LPN/VN.

Which action should the nurse take when teaching a patient with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a high-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching. d. Wait until family members have left before initiating teaching.

c. Ask for permission to turn off the television before teaching. Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching.

A patient reports difficulty falling asleep and daytime fatigue for the past 6 weeks. What is the best initial action for the nurse to take in determining whether this patient has chronic insomnia? a. Schedule a polysomnograph (PSG). b. Teach the patient about good sleep hygiene. c. Ask the patient to keep a 2-week sleep diary. d. Arrange for the patient to have a sleep study.

c. Ask the patient to keep a 2-week sleep diary. The diagnosis of insomnia is made on the basis of subjective reports and an evaluation of a 1- to 2-week sleep diary completed by the patient. PSG studies or sleep studies may be used for determining specific sleep disorders but are not necessary to make an initial insomnia diagnosis. Teaching the patient good sleep habits may be useful, but that will not help to assess for chronic insomnia.

A hospitalized older patient reports his foreskin is retracted and will not return to normal. Which action is the priority? a. Start oral antibiotics. b. Apply ice to reduce swelling. c. Attempt to move the foreskin over the glans. d. Call the provider to prepare for circumcision.

c. Attempt to move the foreskin over the glans. Paraphimosis can occur when the foreskin is pulled back during bathing, during catheter insertion, or after intercourse and not returned to the normal position. Attempting to return the foreskin over glans is the priority action. If the nurse is unsuccessful, then ice would be applied to decrease swelling. If the foreskin is not returned to the normal position manually by the health care provider, then circumcision would be indicated. Paraphimosis is considered a urologic emergency because arterial blood flow to the glans penis is impaired.

The nurse teaches a 30-yr-old man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? a. Hamburger with cheese, pudding, and coffee b. Grilled steak, French fries, and vanilla shake c. Baked chicken, peas, apple slices, and skim milk d. Grilled cheese sandwich, onion rings, and hot tea

c. Baked chicken, peas, apple slices, and skim milk A diet high in red meat and high-fat dairy products along with a low intake of vegetables and fruits may increase the risk of prostate cancer.

The nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH. Which test result would confirm the diagnosis? a. Digital rectal examination b. Serum phosphatase level c. Biopsy of prostatic tissue d. Massage of prostatic fluid

c. Biopsy of prostatic tissue A definitive diagnosis of the cellular changes associated with BPH is made by biopsy, with subsequent microscopic evaluation. Palpation of the prostate gland through rectal examination is not a definitive diagnosis; this only reveals size and configuration of the prostate. The serum phosphatase level will provide information for prostatic cancer; a definitive diagnosis cannot be made with this test for BPH. A sample of prostatic fluid helps diagnose prostatitis.

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine volume b. Calcium level c. Cardiac rhythm d. Neurologic status

c. Cardiac rhythm The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the patient's most recent potassium level. d. Review the chart for the patient's current creatinine level.

c. Check the patient's most recent potassium level. The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be increased in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) reporting shortness of breath and severe eye pain. Which action will the nurse take first? a. Assess cranial nerve functions. b. Administer the prescribed analgesic. c. Check the patient's oxygen saturation. d. Examine the eye for evidence of trauma.

c. Check the patient's oxygen saturation. The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is reporting shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.

A patient who was recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual intercourse. Which action should the nurse take? a. Discuss alternative methods of sexual expression. b. Teach about medication for erectile dysfunction (ED). c. Clarify that TURP does not commonly affect erection. d. Offer reassurance that fertility is not affected by TURP.

c. Clarify that TURP does not commonly affect erection. ED is not a concern with TURP, although retrograde ejaculation is likely, and the nurse should discuss this with the patient. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about fertility does not address his concerns.

A patient is 1 day postoperative after a transurethral resection of the prostate (TURP). Which event is an unexpected finding? a. Requires 2 tablets of Tylenol #3 during the night. b. Reports fatigue and claims to have minimal appetite. c. Continuous bladder irrigation infusing with decreased output. d. Expresses anxiety about his planned discharge home the next day.

c. Continuous bladder irrigation infusing with decreased output. A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient's CBI.

Which nursing intervention is appropriate for a postoperative patient with a history of sleep apnea? a. Padded side rails b. Bedside commode c. Continuous pulse oximetry d. Suction equipment at bedside

c. Continuous pulse oximetry Continuous pulse oximetry is important for postoperative patients with sleep apnea to monitor for hypoxemia. Pain medications and anesthesia are likely to worsen sleep apnea. Padded side rails, bedside commode, and suction equipment are not needed.

The provider has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient? a. Hemodialysis (HD) three times per week b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD)

c. Continuous venovenous hemofiltration (CVVH) CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection. HD three times per week would not be used for this patient because fluid and solutes build up and then are rapidly removed. With APD (used at night instead of during the day) fluid and solutes build up during the day and would not benefit this patient as much. CAPD will not as rapidly remove large amounts of fluid as CVVH can do.

During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? a. Give hypertonic saline. b. Initiate a blood transfusion. c. Decrease the rate of fluid removal. d. Administer antiemetic medications.

c. Decrease the rate of fluid removal. The patient is having hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea but would not help the hypovolemia.

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Acetaminophen b. Calcium phosphate c. Magnesium hydroxide d. Multivitamin with iron

c. Magnesium hydroxide Since magnesium is excreted by the kidneys, patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

To monitor the progression of decreased urinary stream, the nurse should encourage which type of regular screening? a. Uroflowmetry b. Transrectal ultrasound c. Digital rectal examination (DRE) d. Prostate-specific antigen (PSA) monitoring

c. Digital rectal examination (DRE) DRE is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia (BPH) in men older than 50 years of age. The uroflowmetry helps determine the extent of urethral blockage and the type of treatment needed but is not done on a regular basis. Transrectal ultrasound is indicated with an abnormal DRE and elevated PSA to differentiate between BPH and prostate cancer. The PSA monitoring is done to rule out prostate cancer, although levels may be slightly elevated in patients with BPH.

A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? a. Vertigo b. Syncope c. Dizziness d. Nystagmus

c. Dizziness Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down. Nystagmus is an abnormal eye movement that may be observed as a twitching of the eyeball or described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually stimulated by movement of the head. Syncope is a brief lapse in consciousness accompanied by a loss in postural tone (fainting).

Which intervention is most appropriate to treat ongoing insomnia for a middle-aged adult with a busy career? a. Obtain a prescription for zolpidem to be taken at bedtime. b. Suggest having warm milk with a shot of whisky before going to bed. c. Encourage the patient to practice peaceful meditation before bedtime. d. Recommend the use of sleep aids such as triazolam.

c. Encourage the patient to practice peaceful meditation before bedtime. The patient should be encouraged to try nonpharmaceutical methods to reduce stress and reduce insomnia. Meditation is a calming activity that can help prepare the patient to fall asleep. Zolpidem and triazolam should not be taken for long periods of time and carry the risk of side effects. Alcohol disrupts sleep patterns and should be avoided.

A patient on the surgical unit after coronary artery bypass grafting reports having vivid nightmares. What assessment should the nurse complete to determine the most likely cause of the nightmares? a. Ask the patient about a history of posttraumatic stress disorder. b. Determine if the patient has a history of sleep apnea or narcolepsy. c. Evaluate the medications the patient is receiving for possible side effects. d. Review the documentation record to determine if the patient had a fever last night.

c. Evaluate the medications the patient is receiving for possible side effects. Medication side effects are the most common cause of nightmares in patients in acute care settings. Drug classes most likely to cause nightmares are sedative-hypnotics, α-adrenergic antagonists, dopamine agonists, and amphetamines.

What potential cause of infection will the nurse consider in the plan of care for a patient immediately after a perineal radical prostatectomy? a. Urinary incontinence b. Prolonged urinary stasis c. Fecal wound contamination d. Suprapubic catheter placement

c. Fecal wound contamination The perineal approach increases the risk for infection because the incision is located close to the anus, and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery.

What will the nurse will ask the patient about to determine the severity of benign prostatic hyperplasia (BPH) symptoms? a. Blood in the urine b. Lower back or hip pain c. Force of urinary stream d. Erectile dysfunction (ED)

c. Force of urinary stream The American Urological Association Symptom Index for a patient with BPH asks questions such as the force and frequency of urination and nocturia. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH.

When assessing an adult patient's external ear canal and tympanum, what assessment techniques should the nurse use? a. Ask the patient to tip their head toward the nurse. b. Note a pearly gray tympanic membrane as a sign of infection. c. Gently pull the auricle up and backward to straighten the canal. d. Identify a normal light reflex by the appearance of irregular edges.

c. Gently pull the auricle up and backward to straighten the canal. When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. Grasp and gently pull the auricle up and backward to straighten the canal. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex.

A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

c. Glomerular filtration rate (GFR) GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

What is the best intervention to help a school-age child fall asleep at night? a. Encourage exercise in the evening to promote fatigue. b. Provide the child with a high-protein snack before bed. c. Have the parent read a quiet bedtime story to the child. d. Have the child complete homework before going to bed.

c. Have the parent read a quiet bedtime story to the child. A 6-year-old child averages 11 to 12 hours of sleep nightly. Encouraging quiet activities usually persuades the 6- or 7-year-old child to go to bed. Playing an active game, doing homework right before bed, and eating are not quiet activities.

When administering eyedrops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? a. Apply pressure to each eyeball for a few seconds after administration. b. Have the patient close the eyes and move them back and forth several times. c. Have the patient put pressure on the inner canthus of the eye after administration. d. Have the patient try to blink out excess medication immediately after administration.

c. Have the patient put pressure on the inner canthus of the eye after administration Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. The other options will not minimize systemic effects of the medication.

Which complication may develop as a result of frequent middle ear infections as a child? a. Meniere's disease b. Serous otitis media c. Hearing impairment d. Impaction of cerumen

c. Hearing impairment Hearing impairment is common in the United States. At-risk children include those with a family history of childhood hearing impairment, perinatal infection (rubella, herpes, or cytomegalovirus), low birth weight, chronic ear infections, and Down syndrome. Frequent middle ear infections do not lead to impaction of cerumen or Meniere's disease. Serous otitis media is another name for a middle ear infection.

A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

c. Hemoglobin level 13 g/dL High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of greater than 12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP), has an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor? a. Sepsis b. Phlebitis c. Hemorrhage d. Leakage around urinary catheter

c. Hemorrhage After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual, and if it occurs, it will manifest later in the postoperative course. The nurse assesses for phlebitis, but phlebitis is not the most important complication. Hemorrhage is more important than phlebitis. Leaking around the IV catheter is not a major concern.

Which patient assessment finding leads the nurse to suspect that the patient may have central sleep apnea? a. Use of nicotine chewing gum to stop smoking b. History of iron deficiency anemia and hemoglobin 13 g/dL c. History of cervical spine degeneration d. Use of nitrofurantoin to treat urinary tract infection

c. History of cervical spine degeneration Degeneration of the cervical spine can lead to central sleep apnea as the brain fails to send stimuli to breathe. Iron deficiency anemia, nicotine chewing gum, and nitrofurantoin do not lead to central sleep apnea.

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol b. Albuterol c. Ibuprofen d. Acetaminophen

c. Ibuprofen Nonsteroidal antiinflammatory drugs are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

Which nursing diagnosis is most appropriate for a patient with xerostomia? a. Total urinary incontinence related to inability to feel urge to urinate b. Bathing self-care deficit related to inability to perceive left-sided body parts c. Impaired oral mucus membranes related to decreased salivation and dry mouth d. Disturbed sensory perception related to feeling of electric pain in feet and hands

c. Impaired oral mucus membranes related to decreased salivation and dry mouth Xerostomia is a decrease in salivary production leading to dry mouth. This can cause damage to oral mucus membranes. Xerostomia does not include urinary disturbances or neuropathic pain.

A patient newly diagnosed with glaucoma asks the nurse what has made the pressure in the eyes so high. Which is the nurse's most accurate response? a. Back pressure from cardiac congestion causes corneal edema. b. Cerebral venous dilation prevents normal interstitial fluid resorption. c. Increased production of aqueous humor or blocked drainage increases pressure. d. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.

c. Increased production of aqueous humor or blocked drainage increases pressure. Intraocular pressure is increased in glaucoma as a result of excess aqueous humor production or decreased outflow. Cardiac or cerebral circulation changes do not cause glaucoma. Lacrimal anomalies do not affect aqueous humor production.

Which information will the nurse teach a patient who has chronic prostatitis? a. Ibuprofen (Motrin) should provide good pain control. b. Prescribed antibiotics should be taken for 7 to 10 days. c. Intercourse or masturbation will help relieve symptoms. d. Cold packs used every 4 hours will decrease inflammation.

c. Intercourse or masturbation will help relieve symptoms. Ejaculation helps drain the prostate and relieve pain. Warm baths are recommended to reduce pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed but usually do not offer adequate pain relief. Antibiotics for chronic prostatitis are taken for 4 to 12 weeks.

Which information about benign prostatic hyperplasia (BPH) is important for the nurse to consider when caring for a client with that condition? a. It is a congenital abnormality b. A malignancy usually results c. It predisposes to hydronephrosis d. Prostate-specific antigen decreases

c. It predisposes to hydronephrosis Inability to empty the bladder as a result of pressure exerted by the enlarging prostate on the urethra causes a backup of urine into the ureters and finally the kidneys (hydronephrosis). BPH develops over the client's life span; it is not congenital. It is uncommon for BPH to become malignant. Prostate-specific antigen will increase.

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid taken for four years after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine

c. Knee and hip joint pain Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not associated with corticosteroid use.

A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery? a. Hypokalemia b. Hyponatremia c. Large urine output d. Leukocytosis with cloudy urine output

c. Large urine output Patients often have diuresis in the hours and days immediately after a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.

How can the nurse best assist a hospitalized young child to fall asleep? a. Eliminate a daytime nap. b. Offer the child warm chocolate milk. c. Maintain the child's home bedtime routine. d. Allow the child to sleep longer in the morning.

c. Maintain the child's home bedtime routine. A bedtime routine (e.g., same hour for bedtime or quiet activity) used consistently helps toddlers and preschool children avoid delaying sleep. Parents need to reinforce patterns of preparing for bedtime. Reading stories, allowing children to sit in a parent's lap while listening to music or praying, and coloring are routines associated with preparing for bed. Toddlers still need naps. Sleeping longer will continue to disrupt the normal routine. Chocolate can cause a person to stay awake or wake up throughout the night.

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. What is the nurse's most important action during the initial assessment? a. Obtain more information about the cause of the patient's vision loss. b. Obtain information from the spouse about the patient's special needs. c. Make eye contact with the patient and ask about any need for assistance. d. Perform an evaluation of the patient's visual acuity using a Snellen chart.

c. Make eye contact with the patient and ask about any need for assistance. Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked first about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment.

The nurse is caring for a patient who is diagnosed with narcolepsy and cataplexy. What therapeutic drug regimen will the nurse educate the patient about? a. Valerian and diazepam b. Melatonin and ropinirole c. Modafinil and desipramine d. Diphenhydramine and low-dose fluoxetine

c. Modafinil and desipramine Narcolepsy drug management includes amphetamine-like stimulants or nonamphetamine wake-promotion drugs (e.g., modafinil) to relieve excessive daytime sleepiness and antidepressant drug therapy (e.g., desipramine) to control cataplexy. Drugs that often cause drowsiness such as diazepam, melatonin, and diphenhydramine are not indicated for use in patients with narcolepsy.

After a transurethral prostatectomy (TURP), a client returns to the postanesthesia care unit with a three-way indwelling catheter and a continuous bladder irrigation. Which nursing action would the nurse monitor during the initial recovery phase? a. Observe the suprapubic dressing for drainage. b. Maintain the client in a semi-Fowler position. c. Monitor for bright red blood in the urinary drainage bag. d. Encourage fluids by mouth as soon as the gag reflex returns.

c. Monitor for bright red blood in the urinary drainage bag. Blood clots are normal 24 to 36 hours after the TURP surgery, but bright red blood can indicate hemorrhage. The surgeon performs the surgery by accessing the prostate through the urinary meatus and urethra; there is no suprapubic incision. The client does not need to maintain a semi-Fowler position. Initially, the client may not have anything by mouth (NPO) until the gag reflex returns and the anesthesia nausea decreases. Then the client advances to clear liquids and to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.

Otoscopic examination of the patient's left ear indicates the presence of an exostosis. What does the nurse teach the patient about regarding the growth? a. Surgery b. Electrocochleography c. Monitoring of the growth d. Irrigation of the ear canal

c. Monitoring of the growth An exostosis is a bony growth into the ear canal that normally does not require intervention or correction.

The patient has a history of cardiovascular disease and has developed erectile dysfunction. He is frustrated because he is taking nitrates and cannot take erectogenic medications. What should the nurse do first? a. Give the patient choices for penile implant surgery. b. Recommend counseling for the patient and his partner. c. Obtain a thorough sexual, health, and psychosocial history. d. Assess levels of testosterone, prolactin, luteinizing hormone, and thyroid hormones.

c. Obtain a thorough sexual, health, and psychosocial history. The nurse's first action to help this patient is to obtain a thorough sexual, health, and psychosocial history. Alternative treatments for the cardiac disease would then be explored if that had not already been done. Further examination or diagnostic testing would be based on the history and physical assessment, including hormone levels, counseling, or penile implant options.

A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first? a. Insert a urinary retention catheter. b. Administer epoetin alfa (Epogen). c. Place the patient on a cardiac monitor. d. Give sodium polystyrene sulfonate (Kayexalate).

c. Place the patient on a cardiac monitor. Because hyperkalemia can cause fatal dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

Which term will the nurse use to document the patient's age-related hearing loss? a. Tinnitus b. Meniere's disease c. Presbycusis d. Presbyopia

c. Presbycusis Hearing changes often associated with aging include decreased hearing acuity, speech intelligibility, and pitch discrimination, which is referred to as presbycusis. Low-pitched sounds are easiest to hear, but it is difficult to hear conversation over background noise. A decrease in active sebaceous glands causes the cerumen to become dry and completely obstruct the external auditory canal. Tinnitus is commonly caused by ototoxicity and patients experience the sensation of ringing in the ears. Presbyopia refers to the gradual decline in ability of the lens to accommodate or focus on close objects and reduces ability to see near objects clearly. Although the cause of Meniere's disease is unknown, the symptoms include progressive low-frequency hearing loss, vertigo, tinnitus, and a full feeling or pressure in the affected ear.

During a health history, a 43-yr-old teacher reports increasing difficulty reading printed materials for the past year. What change related to aging does the nurse suspect? a. Myopia b. Hyperopia c. Presbyopia d. Astigmatism

c. Presbyopia Presbyopia is a loss of accommodation causing an inability to focus on near objects. This occurs as a normal part of aging process starting around age 40 years. Myopia is nearsightedness (near objects are clear and far objects are blurred). Astigmatism results in visual distortion related to unevenness in the cornea. Hyperopia is farsightedness (near objects are blurred and far objects are clearly seen).

A 53-yr-old patient is scheduled for an annual physical examination. What diagnostic test will the nurse will plan to explain to the patient? a. Urinalysis collection b. Uroflowmetry studies c. Prostate-specific antigen (PSA) d. Transrectal ultrasound scanning (TRUS)

c. Prostate-specific antigen (PSA) An annual digital rectal exam (DRE) and PSA are usually recommended starting at age 50 years for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA results are abnormal.

An older adult reports occasional insomnia. Which information obtained by the nurse indicates a need for patient teaching? (Select all that apply.) a. Drinks a cup of coffee every morning with breakfast. b. Eats a snack every evening 1 hour before going to bed. c. Reads or watches television in bed on most evenings. d. Takes a warm bath just before bedtime every night. e. Uses diphenhydramine as an occasional sleep aid.

c. Reads or watches television in bed on most evenings. e. Uses diphenhydramine as an occasional sleep aid. Reading and watching television in bed may contribute to insomnia. Older adults should avoid the use of medications that have anticholinergic effects, such as diphenhydramine. Having a snack 1 hour before bedtime or coffee early in the day should not affect sleep quality. Rituals such as a warm bath before bedtime can enhance sleep quality.

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

c. Remind the patient it may take months to restore vision after transplant. Vision may not be restored for up to 1 year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery.

Which intervention will be included in the plan of care for a patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? a. Start continuous pulse oximetry. b. Restrict the patient's protein intake. c. Restrict physical activity to bed rest. d. Discontinue the urethral retention catheter.

c. Restrict physical activity to bed rest. The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

Which is the priority nursing diagnosis for a patient who has been diagnosed with Meniere's disease? a. Nausea related to constant sensation of noxious taste b. Acute confusion related to delirium and disorientation c. Risk for falls related to unsteadiness and loss of balance d. Autonomic dysreflexia related to distention of bowel or bladder

c. Risk for falls related to unsteadiness and loss of balance Meniere's disease causes vertigo, a sensation of the environment spinning. This causes the patient to be unsteady and at high risk for falls. Nausea is less of a priority than falls. Meniere's disease does not cause confusion or autonomic dysreflexia.

A patient has had no visitors during a lengthy hospitalization. The patient is bored, restless, and irritable. Which term best describes the patient's feelings? a. Sensory deficits b. Sensory overload c. Sensory deprivation d. Changes in attitudes

c. Sensory deprivation Sensory deprivation occurs when inadequate quality or quantity of stimuli impairs a patient's perception. It can cause affective changes (e.g., boredom, restlessness, increased anxiety, emotional lability) and/or perceptual changes (e.g., reduced attention span, disorganized visual and motor coordination, confusion of sleeping and waking states). Sensory deficits such as low vision and blindness are very common forms of disability. When a person receives multiple sensory stimuli, the brain has difficulty distinguishing the stimuli, leading to sensory overload. A person with sensory overload no longer perceives the environment in a way that makes sense. Sensory deprivation can be caused from living in a nonstimulating environment. Ask the patient how to improve the quality of stimulation in the environment.

The patient has a low-grade cancer on the left lateral aspect of the prostate gland and has been on "watchful waiting" status for 5 years. Six months ago, his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations indicate prostate cancer may be extending and require a change in the plan of care? (Select all that apply.) a. Casts in his urine b. Presence of α-fetoprotein c. Serum PSA level 10 ng/mL d. Onset of erectile dysfunction e. Nodularity of the prostate gland f. Development of a urinary tract infection

c. Serum PSA level 10 ng/mL e. Nodularity of the prostate gland The manifestations of increased PSA level along with the new nodularity of the prostate gland potentially indicate that the tumor may be growing. Casts in the urine, presence of α-fetoprotein, and new onset of erectile dysfunction do not indicate prostate cancer growth. Development of a urinary tract infection may indicate urinary retention or could be related to other issues.

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin. What should the nurse monitor for adverse effects of the medication? a. Blood glucose b. Urine osmolality c. Serum creatinine d. Serum potassium

c. Serum creatinine When a patient with diabetes, which increases risk for chronic kidney disease (CKD), receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in assessing for the adverse effects of the gentamicin.

A patient is experiencing insufficient sleep and having health issues as a result. What disorder does the nurse teach the patient can be related to sleep disorders? a. Insufficient sleep is linked to a decreased risk for type 2 diabetes. b. Inadequate sleep in people with hypertension decreases blood pressure. c. Short sleep duration may cause metabolic changes that are linked to obesity. d. Radiation for cancer treatment is associated with fragmented sleep and fatigue.

c. Short sleep duration may cause metabolic changes that are linked to obesity. Short sleep duration may result in metabolic changes that are linked to obesity. Insufficient sleep is linked to an increased risk for type 2 diabetes. Inadequate sleep leads to further elevations in blood pressure in people with hypertension. Chemotherapy for cancer treatment is associated with fragmented sleep and fatigue, but inadequate sleep does not contribute to cancer.

A patient is seeking care for problems related to an inability to sleep and stay asleep over the past several months. What is an important first step the nurse teaches the patient to improve sleep quality? a. Melatonin b. Benzodiazepines c. Sleep hygiene practices d. Over-the-counter sleep aids

c. Sleep hygiene practices Sleep hygiene practices are effective in the management of insomnia and should be the first line of therapy. Melatonin may be helpful for jet lag but has a short duration of action. Benzodiazepines have a prolonged half-life and may result in daytime sleepiness. Over-the-counter sleep aids may lead to tolerance or have anticholinergic side effects.

An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Increase the speaking volume. b. Overenunciate while speaking. c. Speak normally but more slowly. d. Use more facial expressions when talking.

c. Speak normally but more slowly. Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend.

A licensed practical/vocational nurse (LPN/VN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/VN assists the patient to ambulate in the hallway. b. The LPN/VN administers the erythropoietin subcutaneously. c. The LPN/VN administers the iron supplement and phosphate binder with lunch. d. The LPN/VN carries a tray containing low-protein foods into the patient's room.

c. The LPN/VN administers the iron supplement and phosphate binder with lunch. Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/VN are appropriate for a patient with renal insufficiency.

Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching? a. The UAP apply a cold pack to the scrotum for a patient with mumps orchitis. b. The UAP help a patient who has had a prostatectomy to put on antiembolism hose. c. The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter. d. The UAP encourage a high oral fluid intake for patient who had transurethral resection of the prostate yesterday.

c. The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter. Paraphimosis can be caused by failing to replace the foreskin back over the glans after cleaning. The other actions by UAP are appropriate.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while in the bathtub each day. d. The patient slows the inflow rate when experiencing abdominal pain.

c. The patient cleans the catheter while in the bathtub each day. Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

Why will the patient with sleep apnea be encouraged to use the CPAP machine while in the hospital after surgery? a. It will keep the patient in deep levels of REM, which will decrease the need for pain medication. b. It will help decrease noise from the roommate and hospital environment that may keep the patient awake. c. The patient needs ventilator support owing to the increased chance of postoperative respiratory complications. d. The patient needs to follow the same bedtime routine to promote a safe environment for sleep.

c. The patient needs ventilator support owing to the increased chance of postoperative respiratory complications. These patients need ventilator support in the postoperative period because obstructive sleep apnea is linked to increased postoperative respiratory complications. After surgery, the patient achieves very deep levels of REM sleep that lead to muscle relaxation and airway obstruction. In these patients, the anesthesia in combination with pain medications used after surgery reduces the patient's defenses against airway obstruction. Make sure that patients use their home CPAP equipment. Use pain medication carefully in these patients. Promoting the home bedtime routine is beneficial, but that is not the primary reason for using the CPAP; it is to prevent complications from surgery.

A patient in the emergency department reports being struck in the right eye with a fist. Which finding is a priority for the nurse to communicate to the health care provider? a. The patient reports a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The patient reports "a curtain" over part of the visual field. d. The area around the right eye is bruised and tender to the touch.

c. The patient reports "a curtain" over part of the visual field. The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye.

Which team member is responsible for intervening when a health care professional wants to leave a session for health care professionals who are experiencing insomnia after working in a mass casualty incident? a. Police b. Paramedic c. Fire Fighter d. Doorkeeper

d. Doorkeeper The "doorkeeper" is responsible for keeping inappropriate people out of the session and talking with health care professionals who are leaving the session early in an effort to have him or her return. Police and paramedics are the debriefing team members who are used based on the needs of the group. Firefighters are first responders who rescue people from danger after a disaster event.

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is important to report to the health care provider before the procedure? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes antihypertensive medications. d. The patient gets nauseated with general anesthesia.

c. The patient takes antihypertensive medications. Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia.

Which is the appropriate outcome for a patient with the nursing diagnosis insomnia related to overwhelming parental and job responsibilities? a. The patient will sleep longer throughout the night. b. The patient will wake up more refreshed in the morning. c. The patient will fall asleep within 30 minutes of going to bed. d. The patient will take a warm bath nightly before going to bed.

c. The patient will fall asleep within 30 minutes of going to bed. Falling asleep within 30 minutes of going to bed is a measurable, appropriate goal. Waking up more refreshed or sleeping longer is not measurable. Taking a warm bath before bed is an intervention rather than a goal.

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will the nurse include in the discharge teaching plan? a. The use of eye patches to reduce movement of the operative eye b. The need to wear dark glasses to protect the eyes from bright light c. The purpose of maintaining the head resting in a prescribed position d. The procedure for dressing changes when the eye dressing is saturated

c. The purpose of maintaining the head resting in a prescribed position Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. Dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure.

What health history information should the nurse obtain from the patient who has possible testicular cancer? a. Testicular torsion b. Testicular trauma c. Undescended testicles d. Sexually transmitted infection (STI)

c. Undescended testicles Cryptorchidism, or undescended testicles, is a risk factor for testicular cancer if it is not corrected before puberty. STI, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer.

What should the nurse teach a patient with recurrent staphylococcal and seborrheic blepharitis to do? a. Irrigate the eyes with saline solution. b. Schedule an appointment for eye surgery. c. Use a gentle baby shampoo to clean the eyelids. d. Apply cool compresses to the eyes three times daily.

c. Use a gentle baby shampoo to clean the eyelids. Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? a. Initiate coping strategies to reduce stress. b. Identify patient's strengths and support system. c. Verbalize feelings related to visual impairment. d. Transition successfully to the sudden vision loss.

c. Verbalize feelings related to visual impairment. The nurse's priority is to help the patient express his feelings about the vision loss resulting from the lack of coping effectively with the situation. Until the patient expresses how they feel, they will be unable to progress in the rehabilitation process.

What is the safest technique for the nurse to use when assisting a blind patient to ambulate to the bathroom? a. Lead the patient slowly to the bathroom, holding on to the patient by the arm. b. Stay beside the patient and describe any obstacles on the path to the bathroom. c. Walk slightly ahead of the patient, allowing the patient to hold the nurse's elbow. d. Have the patient place a hand on the nurse's shoulder and guide the patient forward.

c. Walk slightly ahead of the patient, allowing the patient to hold the nurse's elbow. When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.

A registered nurse is teaching a student about factors that influence sleep. Which scenario explained by the registered nurse is an example of a lifestyle factor? a. "A client reports trouble falling asleep because of thinking about stress at work" b. "A client in the intensive care unit has not slept properly because of noises and disturbances" c. "A client who has been taking antidepressants reports drowsiness and a lack of sleep" d. "A client who works rotating overnight shifts reports fatigue and difficulty sleeping through the night"

d. "A client who works rotating overnight shifts reports fatigue and difficulty sleeping through the night" An individual's lifestyle can influence his or her sleep patterns. Working irregular rotating overnight shifts will throw off a client's biological clock, disrupting sleep. This is an example of a lifestyle factor. When a client reports inadequate sleep due to work stress, this is an example of an emotional stress factor affecting sleep. When a client in the intensive care unit says he or she has not been able to sleep properly because of noises and disturbances, this is an example of an environmental factor affecting sleep. When a client who has been taking antidepressants reports excess drowsiness and lack of sleep, this is an example of a medications and substances factor affecting sleep.

A patient with chronic insomnia asks the nurse about ways to improve sleep quality. Which response by the nurse is accurate? a. "Avoid exercising during the day." b. "Keep the bedroom temperature warm." c. "Read in bed for a few minutes each night." d. "Go to bed at the same time every evening."

d. "Go to bed at the same time every evening." A regular evening schedule is recommended to improve sleep time and quality. Aerobic exercise may improve sleep quality but should occur at least 6 hours before bedtime. Reading in bed is discouraged for patients with insomnia. The bedroom temperature should be slightly cool.

The nurse is assessing an older adult patient who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess for the presence of presbycusis? a. "Do you ever experience any ringing in your ears?" b. "Have you ever fallen down because you became dizzy?" c. "Do you ever have pain in your ears when you're chewing or swallowing?" d. "Have you noticed any change in your hearing in recent months and years?"

d. "Have you noticed any change in your hearing in recent months and years?" Presbycusis is an age-related change in auditory acuity. Whereas ringing in the ears is termed tinnitus, dizziness and falls are related to balance and the function of the vestibular system. Presbycusis is not associated with pain during chewing and swallowing.

The nurse is teaching a patient about timolol eyedrops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? a. "I may feel some palpitations after instilling these eyedrops." b. "I should withhold this medication if my blood pressure becomes elevated." c. "I should keep my eyes closed for 15 minutes after instilling these eyedrops." d. "I may have some temporary blurring of vision after instilling these eyedrops."

d. "I may have some temporary blurring of vision after instilling these eyedrops." It is common for patients to have a temporary blurring of vision for a few minutes after instilling eyedrops. This should not cause concern to the patient. Because timolol is a β-blocker, heart rate may slow, and blood pressure is more likely to decrease if absorbed systemically.

The nurse teaches a patient prescribed dipivefrin eyedrops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? a. "The eyedrops could cause a fast heart rate and high blood pressure." b. "I will need to take the eyedrops twice a day for at least 2 to 3 months." c. "I may have eye discomfort and redness from the use of these eyedrops." d. "I will apply gentle pressure on the inside corner of my eye after each eyedrop."

d. "I will apply gentle pressure on the inside corner of my eye after each eyedrop." To avoid systemic reactions such as tachycardia and hypertension, the patient should apply punctual occlusion after instillation of the eyedrops. Dipivefrin will control chronic open-angle glaucoma but will not cure the disease. Side effects associated with dipivefrin include ocular discomfort and redness, tachycardia, and hypertension.

A patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will use drops to keep my pupils dilated until my appointment." b. "I will need to use brighter lights to read for at least the next week." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

d. "I will cover up with long-sleeved shirts and pants for the next 5 days." The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? a. "Prolonged eye irritation is an expected adverse effect of this medication." b. "This medication will help to raise intraocular pressure to a near normal level." c. "This medication needs to be continued for at least 5 years after your initial diagnosis." d. "It is important not to do activities requiring visual acuity immediately after administration."

d. "It is important not to do activities requiring visual acuity immediately after administration." Pilocarpine causes blurred vision and difficulty in focusing, so it is important not to engage in any activities requiring visual acuity until the vision clears. It should not cause prolonged eye irritation, and this should be immediately reported to the prescribing care provider. This medication will decrease intraocular pressure.

The parent is concerned because the child has been referred to an optometrist after a routine eye screening at school. What is the nurse's most appropriate response to the parent? a. "Most children have a mild form of color blindness as their eyes mature." b. "You should wash the child's eyelids every morning with a damp washcloth." c. "It is normal for children to squint to see but it should be checked out anyway." d. "Most likely your child will need glasses to see the teacher and board at school."

d. "Most likely your child will need glasses to see the teacher and board at school." The most common visual problem during childhood is a refractive error such as nearsightedness. The parent can be told that the child may likely require glasses in order to see clearly over far distances. Color blindness is not common in childhood and only affects males. Squinting is not normal at any age. Washing the child's eyelids every morning will not affect the child's need for corrective lenses.

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response would the nurse provide? a. "Your urine will be pink and free of clots" b. "You will have an abdominal incision and a dressing" c. "There will be an incision between your scrotum and rectum" d. "There will be a urinary catheter and a continuous bladder irrigation"

d. "There will be a urinary catheter and a continuous bladder irrigation" The presence of an indwelling urinary catheter and a continuous bladder irrigation are routine postoperative expectations after a TURP; they provide for homeostasis and urinary excretion. An abdominal incision and dressing are present with a suprapubic, not transurethral, prostatectomy. After a TURP, the client initially can expect hematuria and some blood clots; the continuous bladder irrigation keeps the bladder free of clots and the catheter patent. An incision between the scrotum and rectum is associated with a perineal prostatectomy, not a TURP.

A frail 86-yr-old woman with stage 3 chronic kidney disease is cared for at home by her family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications should the nurse teach the patient to avoid? a. Aspirin b. Acetaminophen c. Diphenhydramine d. Aluminum hydroxide

d. Aluminum hydroxide Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.

A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? a. Teach about visual enhancement techniques. b. Assess coping strategies and support systems. c. Teach nutritional strategies to improve vision. d. Assess impact of vision on normal functioning.

d. Assess impact of vision on normal functioning. The most important nursing intervention is to assess the patient's ability to function with the visual impairment. The nurse will use this information to plan nursing care, including assessment of the patient's coping strategies and teaching about vision enhancement techniques and nutrition.

Which information would the nurse provide to a client with insomnia to prevent injury? a. Use melatonin for sleep b. Watch television before bed c. Refrain from daytime napping d. Avoid sedative use before activities

d. Avoid sedative use before activities Sedatives can cause drowsiness; therefore, clients would be advised not to take them before activities such as working or driving. Melatonin is a naturally occurring hormone that can be used to promote sleep. Watching television before bed and daytime napping may interfere with the sleep cycle, but these actions do not lead to injuries.

A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. The digital rectal examination report indicates smooth, firm, and enlarged prostate tissue surrounding the urethra. Which condition would the nurse suspect? a. Prostatitis b. Paraphimosis c. Prostate cancer d. Benign prostatic hyperplasia (BPH)

d. Benign prostatic hyperplasia (BPH) BPH is a benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in the prostate cells, which can stimulate cell growth and overgrowth of prostate tissue surrounding the urethra. The clinical manifestations of BPH include nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. Presence of fever, chills, back pain, and perineal pain, along with acute urinary symptoms such as dysuria. urinary frequency, urgency, and cloudy urine indicate prostatitis, which involves inflammation of the prostate gland. Paraphimosis is a tightness of the penis foreskin that results in the inability to pull the skin forward from the retracted position and prevents normal return of the skin over the glans. Symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, and leaking or dribbling.

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Antibiotics are infused continuously through the bladder irrigation. d. Bladder irrigation prevents obstruction of the catheter after surgery.

d. Bladder irrigation prevents obstruction of the catheter after surgery. The purpose of bladder irrigation is to remove clots from the bladder and prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation.

A patient with a 25-year history of type 1 diabetes is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood glucose levels. Which diagnostic study is most indicative of chronic kidney disease (CKD)? a. Serum creatinine b. Serum potassium c. Microalbuminuria d. Calculated glomerular filtration rate (GFR)

d. Calculated glomerular filtration rate (GFR) The best study to determine kidney function or CKD that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

The health care provider prescribes the following interventions for a patient with acute prostatitis caused by Escherichia coli. Which intervention should the nurse question? a. Give trimethoprim/sulfamethoxazole 1 tablet daily for 28 days. b. Administer ibuprofen 400 mg every 8 hours as needed for pain. c. Instruct patient to avoid sexual intercourse until treatment is complete. d. Catheterize the patient as needed if symptoms of urinary retention develop.

d. Catheterize the patient as needed if symptoms of urinary retention develop. Although acute urinary retention may occur, insertion of a catheter through an inflamed urethra is contraindicated, and the nurse will anticipate that the health care provider will need to insert a suprapubic catheter. The other actions are appropriate.

During the course of a health history to assess vision, a patient reports dry eyes. What should the nurse assess next? a. Assess for contact lenses. b. Suggest saline eyedrops. c. Ask about eyeglass usage. d. Check the medication list.

d. Check the medication list. The nurse should evaluate the patient's medication list to identify agents that can contribute to dry eyes so follow-up nursing care can be planned. Dry eyes aggravate wearing contact lenses, but contact lenses do not normally cause dry eyes. The nurse should not suggest saline eyedrops until the etiology of the dry eyes is determined. Eyeglasses do not cause dry eyes.

A patient in the intensive care unit is becoming more irritable from lack of sleep. What nursing action will best help facilitate the patient's sleeping? a. Give the patient a back rub. b. Keep the lights on during the day. c. Talk to the patient when waking up at night. d. Cluster activities to allow longer rest periods.

d. Cluster activities to allow longer rest periods. Combining patient care activities to avoid frequently disturbing the patient's sleep will help the patient get more sleep and thus be less irritable. A back rub may help, but keeping the lights off in the room at night and only talking to the patient if the patient wants to talk will best facilitate sleep.

To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic? a. Perform tympanometry. b. Schedule otoscopic examinations. c. Administer influenza immunizations. d. Discuss exposure to amplified music.

d. Discuss exposure to amplified music. The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to highly amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients.

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)? a. IV tobramycin b. Incompatible blood transfusion c. Poststreptococcal glomerulonephritis d. Dissecting abdominal aortic aneurysm

d. Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststreptococcal glomerulonephritis are intrarenal causes of AKI.

The charge nurse is observing a new nurse who is caring for a patient with vestibular disease. For what action by the nurse should the charge nurse intervene immediately? a. Facing the patient directly when speaking b. Speaking slowly and distinctly to the patient c. Administering both the Rinne and Weber tests d. Encouraging the patient to ambulate independently

d. Encouraging the patient to ambulate independently Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

Which activities would the nurse recommend to a client who asks for advice about insomnia? Select all that apply. One, some, or all responses may be correct. a. Drink a glass of wine b. Engage in vigorous exercise before bedtime c. Eat foods containing lysine d. Follow the same bedtime ritual each night e. Perform deep-breathing exercises

d. Follow the same bedtime ritual each night e. Perform deep-breathing exercises A bedtime ritual provides a familiar routine that promotes comfort and the self-fulfilling prophesy of sleep. Relaxation exercises slow body processes and reduce tension, both of which facilitate rest and promote sleep. People who drink alcohol may fall asleep more quickly but have depressed levels of rapid eye movement, less stage 4 sleep, and interruptions between sleep stages (sleep fragmentation). Physical exercise before bedtime has a stimulating rather than a relaxing effect. Lysine, an amino acid, maintains nitrogen equilibrium and promotes growth and development, but it does not influence sleep.

A patient reports leg cramps during hemodialysis. What action should the nurse take? a. Massage the patient's legs. b. Reposition the patient supine. c. Give acetaminophen (Tylenol). d. Infuse a bolus of normal saline

d. Infuse a bolus of normal saline Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? a. Inner canthus b. Outer canthus c. Center of the eyeball d. Lower conjunctival sac

d. Lower conjunctival sac Ocular medications, such as pilocarpine, should be instilled into the lower conjunctival sac. Never apply eyedrops directly to the cornea. Applying the drops to the inner canthus will cause them to be distributed systemically.

Although the patient can see movement in the periphery, the patient can no longer see to read books or do crossword puzzles. Which is the most likely cause of the patient's vision loss? a. Cataracts b. Glaucoma c. Diabetic retinopathy d. Macular degeneration

d. Macular degeneration Age-related macular degeneration occurs when the macula (specialized portion of the retina responsible for central vision) degenerates as a result of aging and loses its ability to function efficiently. An early sign includes distortion that causes edges or lines to appear wavy. In later stages, patients may see dark or empty spaces that block the center of vision. Cataract is clouding of the lens in the eye that affects vision. Interferes with passage of light through the lens and reduces the light that reaches the retina. Cataracts usually develop gradually and often result in cloudy or blurry vision, glare, double vision, and poor night vision. Glaucoma is a slowly progressive increase in intraocular pressure that causes progressive pressure against the optic nerve. At first, vision stays normal, and there is no pain. If left untreated, there may be a loss of peripheral (side vision). Diabetic retinopathy are pathological changes of the blood vessels of the retina secondary to increased pressure resulting in hemorrhage, macular edema, and reduced vision or vision loss.

After a transurethral resection of the prostate (TURP), a 64-yr-old patient with continuous bladder irrigation reports painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take first? a. Increase the flowrate of the bladder irrigation. b. Administer the prescribed IV morphine sulfate. c. Give the patient the prescribed belladonna and opium suppository. d. Manually instill and then withdraw 50 mL of saline into the catheter.

d. Manually instill and then withdraw 50 mL of saline into the catheter. The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flowrate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot.

Which assessment finding indicates that the patient has developed diabetes-induced peripheral neuropathy? a. The nurse must speak louder than usual to be understood by the patient. b. Fine tremors of the hands that worsen when the patient tries to eat or write. c. Painful muscle spasms with hyperreactive Achilles and quadriceps reflexes. d. No pain is felt when the patient's feet are burned after walking on hot pavement.

d. No pain is felt when the patient's feet are burned after walking on hot pavement. Diabetic peripheral neuropathy may present with pain or loss of sensation in the extremities, particularly the feet. The patient who does not feel pain when the feet are burned is experiencing peripheral neuropathy. Diabetic peripheral neuropathy does not affect hearing or cause tremors or muscle spasms.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange. b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level. c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L. d. Patient who has just returned from having hemodialysis with a heart rate of 110/min.

d. Patient who has just returned from having hemodialysis with a heart rate of 110/min. The patient who has tachycardia after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.

In reviewing a patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. What should the nurse plan to assess? a. Visual acuity b. Pupil reaction c. Color perception d. Peripheral vision

d. Peripheral vision The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.

The nurse preparing to give a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? a. Sodium b. Potassium c. Magnesium d. Phosphorus

d. Phosphorus Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore, administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. Calcium acetate will not have an effect on sodium, potassium, or magnesium levels.

The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-yr-old patient as shown in the accompanying figure, which action should the nurse take first? a. Check the patient's blood glucose level. b. Take the blood pressure on the left arm. c. Use an irrigating syringe to clean the ear canals. d. Report a vision change to the health care provider.

d. Report a vision change to the health care provider. The sudden change in peripheral vision may indicate an acute problem, such as retinal detachment, that should be treated quickly to preserve vision. The other data about the patient are not indicative of any acute problem. The other actions are also appropriate, but the highest priority for this patient is prevention of blindness.

When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Teach the patient how to perform Kegel exercises. b. Monitor for increases in bleeding or presence of clots. c. Increase the flowrate of the irrigation if clots are noted. d. Report any patient reports of pain or spasms to the nurse.

d. Report any patient reports of pain or spasms to the nurse. UAP education and role includes reporting patient concerns to supervising nurses. Patient teaching, assessments for complications, and actions such as bladder irrigation require more education and should be done by licensed nursing staff.

When caring for a patient during the oliguric phase of acute kidney injury (AKI), which nursing action is appropriate? a. Weigh patient three times weekly. b. Increase dietary sodium and potassium. c. Provide a low-protein, high-carbohydrate diet. d. Restrict fluids according to previous daily loss.

d. Restrict fluids according to previous daily loss. Patients in the oliguric phase of AKI will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times each week.

A patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. What should the nurse plan to do? a. Vaccinate the patient with sipuleucel-T (Provenge). b. Provide the patient with information about cryotherapy. c. Teach the patient about placement of intraurethral stents. d. Schedule the patient for annual prostate-specific antigen testing.

d. Schedule the patient for annual prostate-specific antigen testing. Patients who opt for active surveillance need to have annual digital rectal examinations and prostate-specific antigen testing. Vaccination with sipuleucel-T, cryotherapy, and stent placement are options for patients who choose to have active treatment for prostate cancer.

The nurse is caring for a patient with the nursing diagnosis of disturbed sensory perception related to loud, bright hospital environment. Which is the priority intervention for the patient's care plan? a. Maintain eye contact with the patient and avoid chewing gum. b. Ask the patient to repeat information back to ensure understanding. c. Repeatedly orient the patient to time, place, and the hospital room surroundings. d. Shut the patient's door and avoid turning on the bright overhead lights in the room.

d. Shut the patient's door and avoid turning on the bright overhead lights in the room. The nurse should try to reduce the patient's sensory overload by closing the patient's door and avoiding the use of bright overhead lights. Dimmer reading lights should be used whenever possible. Maintaining eye contact, having the patient repeat information, and orienting the patient to the surroundings will not reduce the sensory overload of the bright, loud hospital environment.

The nurse instructs parents to avoid placing their infant in a prone position while sleeping. Which risk would be prevented with this instruction? a. Otitis media of the ear b. Conjunctivitis of the eye c. Infantile colic of baby colic d. Sudden infant death syndrome

d. Sudden infant death syndrome Infants should be placed on their backs while sleeping to prevent sudden infant death syndrome. Sleeping in the prone position can cause respiratory depression and death in infants. Otitis media does not result from sleeping in the prone position. The nurse instructs the parents about proper eye hygiene to prevent conjunctivitis. Infantile colic or baby colic is not caused by placing the infant in the prone position.

Which assessment information collected by the nurse may present a contraindication to a testosterone replacement therapy (TRT)? a. The patient has noticed a decrease in energy level for a few years. b. The patient's symptoms have increased steadily over the past few years. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient has had a gradual decrease in the force of his urinary stream.

d. The patient has had a gradual decrease in the force of his urinary stream. The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate cancer, which are contraindications to the use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a helpful therapy for the patient.

Which assessment finding indicates to the nurse why the patient is having difficulty sleeping at night? a. The patient follows an organic, low-carbohydrate diet. b. The patient enjoys doing crossword puzzles and reading. c. The patient's job includes many hours of hard labor each day. d. The patient now works in Alaska with extended daylight hours.

d. The patient now works in Alaska with extended daylight hours. Northern Alaska has extended daylight hours. Light and temperature affect all circadian rhythms, including the sleep-wake cycle. The most familiar rhythm is the 24-hour, day-night cycle known as the diurnal or circadian rhythm. When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other physiological functions change as well. Low-carbohydrate diet, reading, and manual labor will not cause the patient's sleep problems.

Which assessment is most important to determine if a patient is receiving sufficient sleep? a. Sleep-wake pattern b. Frequency of nocturia c. Hours of sleep each night d. Whether the patient feels rested

d. Whether the patient feels rested Because sleep is a subjective experience, only the patient is able to report whether it is sufficient and restful. Patients are your best resource for describing a sleep problem and any change from their usual sleep and waking patterns. Number of hours of sleep, sleep-wake pattern, and number of times awake for nocturia are not the most important to assess to determine effectiveness of the patient's sleep, the subjective experience of the patient is the most important.

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient reports that the vision has not improved. b. The patient requests a prescription refill for next week. c. The patient feels uncomfortable wearing an eye patch. d. The patient reports eye pain rated 5 (on a 0 to 10 scale).

d. The patient reports eye pain rated 5 (on a 0 to 10 scale). Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring.

Which assessment finding indicates that the patient's CPAP is effectively treating the patient's sleep apnea? a. The patient is able to fall asleep within 30 minutes of going to bed. b. The patient is getting an average of 7 to 8 hours of sleep each night. c. The patient does not require trazodone to fall asleep. d. The patient sleeps through the night without having to get up and urinate.

d. The patient sleeps through the night without having to get up and urinate. Nocturia is a sign of sleep apnea so the patient's ability to sleep through the night without having to get up and urinate indicates that the CPAP therapy is effective. Getting 7 to 8 hours of sleep at night, not requiring trazodone, and falling asleep readily do not indicate effective treatment of sleep apnea.

The nurse is caring for a patient with congestive heart failure. The patient reports frequently waking up at night gasping for air. What is the cause of the patient's awakenings? a. The patient is going to bed too early every night. b. The patient consumed caffeine just before going to bed. c. The patient consumed too much fiber before going to bed. d. The pulse, respirations, and blood pressure drop during sleep.

d. The pulse, respirations, and blood pressure drop during sleep. Heart rate, respirations, and blood pressure drop during sleep. This can cause the patient with congestive heart failure to wake up gasping during the night as the blood oxygenation drops to dangerously low levels. Going to bed early and consuming fiber or caffeine before bed would not cause the patient to wake up gasping for air.

Which finding by the nurse performing an eye examination indicates that the patient has normal accommodation? a. After covering one eye for 1 minute, the pupil constricts as the cover is removed. b. Shining a light into the patient's eye causes pupil constriction in the opposite eye. c. A blink reaction occurs after touching the patient's pupil with a piece of sterile cotton. d. The pupils constrict while fixating on an object being moved toward the patient's eyes.

d. The pupils constrict while fixating on an object being moved toward the patient's eyes. Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object that is being moved from far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

What test will the nurse plan to explain to a 61-yr-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate-specific antigen (PSA) level? a. Cystourethroscopy b. Uroflowmetry studies c. Magnetic resonance imaging (MRI) d. Transrectal ultrasonography (TRUS)

d. Transrectal ultrasonography (TRUS) In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize the prostate for biopsy. Uroflowmetry studies help determine the extent of urine blockage and treatment, but there is no indication that this is a problem for this patient. Cystoscopy may be used before prostatectomy but will not be done until after the TRUS and biopsy. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process.

The nurse in the eye clinic is examining a 67-yr-old patient who says, "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Warn the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

d. Use an ophthalmoscope to examine the posterior eye chambers. Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

A patient with septic shock is receiving multiple medications. The nurse assesses which intravenous (IV) medication is the most likely to cause a hearing loss? a. Aspirin b. Dopamine c. Ampicillin d. Vancomycin

d. Vancomycin The IV medication in use that is most likely to cause a hearing loss is vancomycin (Vancocin) because it is an ototoxic medication. For that reason, serum drug levels are monitored to maintain therapeutic levels and reduce the risk of ototoxicity. Aspirin can also cause hearing loss, but it is not administered IV. Neither dopamine nor ampicillin is likely to cause hearing loss.

How can the nurse assess if an infant is experiencing hearing loss? a. Use an otoscope to ensure that the infant's tympanic membrane is intact. b. Review the infant's medication list for medications that cause ototoxicity. c. Examine the infant's outer ears to check for excessive amounts of cerumen. d. Watch to see if the infant reacts when the nurse's hands are clapped together.

d. Watch to see if the infant reacts when the nurse's hands are clapped together. Neonates without hearing impairments respond to loud noises. Atrophy of the cerumen glands, seen mainly in older adults, cause thicker and dryer wax, which is more difficult to remove and may completely obstruct the auditory canal. Hearing loss can be determined at any age with additional testing by an ENT specialist. Using an otoscope, reviewing the medication list, and examining the infant's outer ears will not assess for hearing loss.

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books? b. How to use a white cane safely? c. Where Braille instruction is available? d. Where to obtain hand-held magnifiers?

d. Where to obtain hand-held magnifiers? Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living. Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.

Which information will the nurse include for a patient considering a cochlear implant? Cochlear implants: a. are not useful for patients with congenital deafness. b. are most helpful as an early intervention for presbycusis. c. improve hearing in patients with conductive hearing loss. d. require extensive training in order to reach the full benefit.

d. require extensive training in order to reach the full benefit. Extensive rehabilitation is required after cochlear implants for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.