Med Surg Exam 4 TB

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A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse notes that the client has a history of dry eyes. The nurse interprets this information as indicating a problem with which structure? A. lacrimal apparatus B. sclera C. cornea D. pupil

A client comes to the ophthalmology clinic for an eye examination. The client tells the nurse that the client often sees floaters in the client's vision. How should the nurse best interpret this subjective assessment finding? A. This is a normal aging process of the eye. B. Glasses will minimize this phenomenon. C. The client may be exhibiting signs of glaucoma. D. This may be a result of weakened ciliary muscles.

A client develops a perforated eardrum. When teaching the client about this condition, the nurse would identify which condition as a most likely cause? A. infection B. otosclerosis C. Meniere disease D. cholesteatoma

A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A. Applying a protective eye shield at night B. Chewing on the affected side to prevent unilateral neglect C. Avoiding the use of analgesics whenever possible D. Avoiding brushing the teeth

A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this client? A. The hearing loss will likely resolve with time after the drug is discontinued. B. The client's hearing loss and tinnitus are irreversible at this point. C. The client's tinnitus is likely multifactorial, and not directly related to aspirin use. D. The client's tinnitus will abate as tolerance to aspirin develops.

A client got a sliver of glass in his/her eye when a glass container at work fell and shattered. The glass had to be surgically removed and the client is about to be discharged home. The client asks the nurse for a topical anesthetic for eye pain. What should the nurse respond? A. "Overuse of these drops could soften your cornea and damage your eye." B. "You could lose the peripheral vision in your eye if you used these drops too much."C. "I'm sorry, this medication is considered a controlled substance and clients cannot take it home." D. "I know these drops will make your eye feel better, but I can't let you take them home."

A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A. Gag reflex B. Deep tendon reflexes C. Abdominal girth D. Hearing acuity

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A. Vigilant monitoring of fluid balance B. Continuous BP monitoring C. Serial arterial blood gases (ABGs) D. Monitoring of the client's airway for patency

A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? A. Explain the location of items using clock cues. B. Explain that each of the items on the tray is clearly separated. C. Describe the location of items from the bottom of the plate to the top. D. Ask the client to describe the location of items before confirming their location.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's level of consciousness (LOC) is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? A. Recognize that this may represent the peak of postsurgical cerebral edema. B. Alert the surgeon to the possibility of an intracranial hemorrhage. C. Understand that the surgery may have been unsuccessful. D. Recognize the need to refer the client to the palliative care team.

A client is postoperative day 6 following tympanoplasty and mastoidectomy. The client has phoned the surgical unit and states experiencing occasional sharp, shooting pains in the affected ear. How should the nurse best interpret this client's report? A. These pains are an expected finding during the first few weeks of recovery. B. The client's report is suggestive of a postoperative infection. C. The client may have experienced a spontaneous rupture of the tympanic membrane. D. The client's surgery may have been unsuccessful.

A client is recovering from intracranial surgery performed approximately 24 hours ago and is reporting a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A. Administer morphine sulfate as prescribed. B. Reposition the client in a prone position. C. Apply a hot pack to the client's scalp. D. Implement distraction techniques.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as physically able. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. The client should remain on bed rest until the client expresses a desire to mobilize. D. Lack of mobility will greatly increase the client's risk of stroke recurrence.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by the diagnosis and the known complications of the disease. How can the client best make known their wishes for care as the disease progresses? A. Prepare an advance directive. B. Designate a most responsible health care provider (MRP) early in the course of the disease. C. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. D. Ensure that witnesses are present when he provides instruction.

A client with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This client's nursing care should involve which of the following? A. Protection of the affected limb from injury B. Passive and active ROM exercises for the affected limb C. Education about improvements to glycemic control D. Interventions to prevent contractures

A client with mastoiditis is admitted to the postsurgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care? A. Assessing for mouth droop and decreased lateral eye gaze B. Assessing for increased middle ear pressure and perforated ear drum C. Assessing for gradual onset of conductive hearing loss and nystagmus D. Assessing for scar tissue and cerumen obstructing the auditory canal

A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client? A. Sit or stand in front of the client when speaking. B. Use exaggerated lip and mouth movements when talking. C. Stand in front of a light or window when speaking. D. Say the client's name loudly before starting to talk.

A client's ocular tumor has necessitated enucleation and the client will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the client's discharge education? A. Disturbed body image B. Chronic pain C. Ineffective protection D. Unilateral neglect

A female client is admitted to the medical unit for evaluation of cerebral metastasis from a primary site. When reviewing the client's history, the nurse would most likely find which site as being the primary site? A. lung B. prostate C. renal D. uterus

A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? A. The effects of brain tumors are often attributed to the cognitive effects of aging. B. Brain tumors in older adults do not normally produce focal effects. C. Older adults typically have numerous benign brain tumors by the eighth decade of life. D. Brain tumors cannot normally be treated in clients over age 75.

A hearing-impaired client is scheduled to have an MRI. What would be important for the nurse to remember when caring for this client? A. Client is likely unable to hear the nurse during test. B. A person adept in sign language must be present during test. C. Lip reading will be the method of communication that is necessary. D. The nurse should interact with the client like any other client.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A. Place the client in a side-lying position. B. Pad the client's bed rails. C. Administer antianxiety medications as prescribed. D. Reassure the client and family members.

A male client presents at the free clinic with reports of erectile dysfunction. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect? A. Prolactinoma B. Angioma C. Glioma D. Adrenocorticotropic hormone (ACTH)-producing adenoma

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? A. Loss of hearing, tinnitus, and vertigo B. Loss of vision, change in mental status, and hyperthermia C. Loss of hearing, increased sodium retention, and hypertension D. Loss of vision, headache, and tachycardia

A nurse is conducting an assessment of a client who is suspected of having a brain tumor. Assessment reveals reports of a headache, for which the nurse gathers additional information. The nurse determines that these reports support the suspicion of a brain tumor when the client reports that the headache occurs: A. early in the morning. B. around lunchtime. C. in the middle of the afternoon. D. at bedtime.

A nurse is interviewing a middle-aged client at the clinic. During the interview, the client states, "I've noticed that I keep having to move the newspaper farther away to read it. Soon my arms will be too short!" The nurse interprets this finding as indicative of which age-related change? A. loss of accommodation B. shrinkage of the vitreous body C. meibomian gland dysfunction (MBG) D. loss of skin elasticity

A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching? A. Care of the cervical collar B. Technique for performing neck ROM exercises C. Home assessment of ABGs D. Techniques for restoring nerve function

A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? A. Instill the medication in the conjunctival sac. B. Maintain a supine position for 10 minutes after administration. C. Keep the eyes closed for 1 to 2 minutes after administration. D. Apply the medication evenly to the sclera

A older adult client comes to the clinic for an evaluation. The client says, "It just doesn't seem like I hear as well as I used to hear." As part of the assessment, the nurse evaluates the client's gross auditory acuity. Which test would the nurse most likely conduct? A. whisper test B. Weber test C. Rinne test D. audiometry

An advanced practice nurse has performed a Rinne test on a new client. During the test, the client reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding? A. The client's hearing is likely normal. B. The client is at risk for tinnitus. C. The client likely has otosclerosis. D. The client likely has sensorineural hearing loss.

An older adult has encouraged the spouse husband to visit their primary provider, stating that concern that spouse may have Parkinson disease. Which description of the spouse's health and function is most suggestive of Parkinson disease? A. "Lately he seems to move far more slowly than he ever has in the past." B. "He often complains that his joints are terribly stiff when he wakes up in the morning." C. "He's forgotten the names of some people that we've known for years." D. "He's losing weight even though he has a ravenous appetite."

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2) C. Administering hypertonic intravenous (IV) solution D. Initiating early mobilization

The advanced practice nurse is attempting to examine the client's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the client's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A. Maintain the irrigation fluid at a warm temperature. B. Instill short, sharp bursts of fluid into the ear canal. C. Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D. Have the client stand during the procedure.

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? A. Increased muscle strength B. Decreased pain C. Improved GI function D. Improved cognition

The nurse caring for a client diagnosed with Parkinson disease has helped prepare a plan of care that would include which goal? A. Promoting effective communication B. Controlling diarrhea C. Preventing optic nerve damage D. Managing choreiform movements

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? A. Disorientation and restlessness B. Decreased pulse and respirations C. Projectile vomiting D. Loss of corneal reflex

The nurse in the ED is caring for a child brought in by the parents who state that the child will not stop crying and pulling at the child's ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? A. External otitis is characterized by aural tenderness. B. External otitis is usually accompanied by a high fever. C. External otitis is usually related to an upper respiratory infection. D. External otitis can be prevented by using cotton-tipped applicators to clean the ear.

The nurse is admitting a 55-year-old client diagnosed with a left eye retinal detachment. While assessing this client, what characteristic symptom would the nurse expect to find? A. Flashing lights in the visual field B. Sudden eye pain C. Loss of color vision D. Colored halos around lights

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A. Fluid restriction B. Transfusion of platelets C. Transfusion of fresh frozen plasma (FFP) D. Electrolyte restriction

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action? A. Inform the care team and assess for further signs of possible increased ICP. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Administer a bolus of normal saline as prescribed.

The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? A. Assessing the client's verbal response B. Assessing the client's ability to follow complex commands C. Assessing the client's judgment D. Assessing the client's response to pain

The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A. Using the incentive spirometer as prescribed B. Maintaining the client on bed rest C. Providing aids to compensate for loss of vision D. Assessing frequently for loss of cognitive function

The nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss? A. The sound is heard better in the ear in which hearing is better. B. The sound is heard equally in both ears. C. The sound is heard better in the ear in which hearing is poorer. D. The sound is heard longer in the ear in which hearing is better.

The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic stroke B. Decrease inflammation C. Hemorrhagic stroke D. Hypertension

The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? A. Seizure B. Hypernatremia C. Airway collapse D. Pneumothorax

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? A. Washing the face B. Exposing the skin to sunlight C. Using artificial tears D. Drinking large amounts of fluids

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? A. Falls B. Audio hallucinations C. Respiratory depression D. Labile BP

The nurse is providing discharge education for a client with a new diagnosis of Ménière disease. What food should the client be instructed to limit or avoid? A. Sweet pickles B. Frozen yogurt C. Shellfish D. Red meat

The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? A. "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." B. "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." C. "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." D. "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? A. MS is a progressive demyelinating disease of the nervous system. B. MS usually occurs more frequently in men. C. MS typically has an acute onset. D. MS is sometimes caused by a bacterial infection.

The nurse should recognize the greatest risk for the development of blindness in which of the following clients? A. A 58-year-old Caucasian woman with macular degeneration B. A 28-year-old Caucasian man with astigmatism C. A 58-year-old black woman with hyperopia D. A 28-year-old black man with myopia

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needs C. Changes in brain activity during sleep and wakefulness D. Temporary changes in metabolism

While inspecting the external eye of a client, the nurse notes that the client's right eyelid droops. Which term would the nurse use to document this finding? A. ptosis B. entropion C. ectropion D. presbyopia

The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. A. Providing frequent small meals rather than three larger meals B. Teaching the client to perform deep breathing and coughing exercises. C. Keeping a urinary catheter in place for the full duration of recovery. D. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. E. Encourage the client to stay in bed and assist with turning and repositioning.

A,B

The nurse is providing care for a client who has benefited from a cochlear implant. The nurse should understand that this client's health history likely includes which of the following? Select all that apply. A. The client was diagnosed with sensorineural hearing loss. B. The client's hearing did not improve appreciably with the use of hearing aids. C. The client has deficits in peripheral nervous function. D. The client's hearing deficit is likely accompanied by a cognitive deficit .E. The client is unable to lip-read.

A,B

A client is exhibiting late signs of increased intracranial pressure. Which finding would the nurse most likely assess? Select all that apply. A. Hypertension B. Bradycardia C. Respiratory depression D. Headache E. Papilledema

A,B,C

A client is scheduled for audiometry to evaluate hearing. When teaching the client about this test, which characteristic would the nurse include as being evaluated? Select all that apply. A. pitch B. frequency C. intensity D. compliance E. postural control capabilities

A,B,C

A family member of a client diagnosed with Huntington disease calls the clinic. The family member is requesting help from the Huntington Disease Society of America. What kind of help can this client and family receive from this organization? Select all that apply. A. Information about this disease B. Referrals C. Public education D. Individual assessments

A,B,C

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. A. Transcranial Doppler flow study B. Cerebral angiography C. MRI D. Cranial radiography E. Electromyography (EMG)

A,B,C

A nurse suspects that an older adult client may be experiencing hearing loss. Which finding would support the nurse's suspicion? Select all that apply. A. Dropping of word endings B. Disinterest in conversations C. Social withdrawal D. Domination of conversations E. Quick decision making

A,B,C,D

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply. A. "Are you exposed to any toxins or chemicals at work?" B. "How would you describe your ability to cope with stress?" C. "What medications are you currently taking?" D. "When was the last time you were hospitalized?" E. "Does anyone else in your family struggle with headaches?"

A,B,C,E

A client with an inoperable brain tumor has been told that the client has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply. A. Pain control B. Management of treatment complications C. Interpretation of diagnostic tests D. Assistance with self-care E. Administration of treatments

A,B,D,E

The nurse is caring for a 77-year-old client with MS. The client is very concerned about the progress of the disease and what the future holds. The nurse should know that older adult clients with MS are known to be particularly concerned about what variables? Select all that apply. A. Possible nursing home placement B. Pain associated with physical therapy C. Increasing disability D. Becoming a burden on the family E. Loss of appetite

A,C,D

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. A. Contractures B. Hemorrhage C. Pressure ulcers D. Venous thromboembolism E. Pneumonia

A,C,D,E

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common cause(s) of blindness and visual impairment among adults over the age of 40? Select all that apply. A. Diabetic retinopathy B. Trauma C. Macular degeneration D. Cytomegalovirus E. Glaucoma

A,C,E

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. Gender E. Age

A,C,E

The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain? Select all that apply. A. Displacing or shifting cerebral spinal fluid (CSF) B. Decreasing cerebral perfusion C. Increasing the absorption of CSF D. Shifting brain tissue E. Decreasing cerebral blood volume

A,C,E

A client is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the client? Select all that apply. A. Application of topical antibiotic ointment B. Maintenance of a supine position for the first 48 hours' postoperative C. Fluid restriction to prevent orbital edema D. Administration of loop diuretics to prevent orbital edema E. Use of an ocular pressure dressing

A,E

A 25-year-old client with brain metastases is considering life expectancy after the client's most recent meeting with her oncologist. Based on the fact that the client is not receiving treatment for the brain metastases, what is the nurse's most appropriate action? A. Promoting the client's functional status and ADLs B. Ensuring that the client receives adequate palliative care C. Ensuring that the family does not tell the client that the condition is terminal D. Promoting adherence to the prescribed medication regimen

A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? A. Reduction in the appearance of new lesions on the MRI B. Decreased muscle spasms in the lower extremities C. Increased muscle strength in the upper extremities D. Decreased severity and duration of exacerbations

A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? A. Whether the tumor utilizes aerobic or anaerobic respiration B. The specific hormones secreted by the tumor C. The client's pre-existing health status D. Whether the tumor is primary or the result of metastasis

A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? A. Permanent improvement after 4 to 6 months of treatment B. Symptom improvement that lasts a few weeks after TPE ceases C. Permanent improvement after 60 to 90 treatments D. Gradual improvement over several months

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? A. Monro-Kellie hypothesis B. Glasgow Coma scale C. Cranial nerve function D. Mental status examination

A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? A. Identify the triggers that precipitated the seizure. B. Implement precautions to ensure the client's safety. C. Teach the client's family about the relationship between brain tumors and seizure activity. D. Ensure that the client is housed in a private room.

A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that eagerness to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond? A. "You have a great attitude. This will likely shorten the amount of time that you need medications." B. "In fact, glaucoma usually requires lifelong treatment with medications." C. "Most people are treated until their intraocular pressure goes below 50 mm Hg." D. "You can likely expect a minimum of 6 months of treatment."

A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client should be kept in a prone position until otherwise ordered. What should the nurse do? A. Clarify the order with the surgeon. B. Follow the order because this bed position is correct. C. Reposition the client after the first dressing change. D. Ask the client to lie in a semi-Fowler position.

A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client reports pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position? A. In the high Fowler position B. In a flat side-lying position C. In the Trendelenburg position D. In the reverse Trendelenburg position

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Have a colleague follow the client closely with a wheelchair. C. Avoid mobilizing the client in the early morning or late evening. D. Ensure that the client's family members do not participate in mobilization.

A client is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière disease. What question is most important for the nurse to ask the client in preparation for this test? A. Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? B. Do you currently take any tranquilizers or stimulants on a regular basis? C. Do you have a history of falls or problems with loss of balance? D. Do you have a history of either high or low blood pressure?

A client newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the client to implement? A. Perform active ROM exercises three times daily. B. Sleep on a firm mattress. C. Apply cool compresses to the back of the neck daily. D. Wear the cervical collar for at least 2 hours at a time.

A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client? A. Generously flush the affected eye with a dilute antibiotic solution. B. Generously flush the affected eye with normal saline or water. C. Apply a patch to the affected eye. D. Apply direct pressure to the affected eye.

A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? A. Negative Brudzinski sign B. Positive Kernig sign C. Hyperpatellar reflex D. Sluggish pupil reaction

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? A. Botulinum toxin type A and heat B. Baclofen and stretching C. Amitriptyline and splinting D. Corticosteroids and acupuncture

A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Arrange for the client to receive a low residue diet. B. Position the client upright during feeding. C. Suction the client following each meal. D. Withhold liquids until the client has finished eating.

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke

A client with hearing loss is scheduled to undergo aural rehabilitation. When describing this therapy, the nurse would include which information as the primary purpose? A. Increase hearing ability. B. Maximize ability to communicate. C. Facilitate use of a hearing aid. D. Limit extraneous noise.

A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? A. Cyclosporine B. Acyclovir C. Cyclobenzaprine D. Ampicillin

A client with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine for pain relief. What principle applies to the administration of this medication? A. Carbamazepine is not known to have serious adverse effects. B. The client should be monitored for bone marrow depression. C. Side effects of the medication include renal dysfunction. D. The medication should be first taken in the maximum dosage form to be effective.

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Pain upon ankle dorsiflexion of the foot B. Neck flexion produces flexion of knees and hips C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? A. Alcohol causes hormone fluctuations. B. Alcohol causes vasodilation of the blood vessels. C. Alcohol has an excitatory effect on the CNS. D. Alcohol diminishes endorphins in the brain.

A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level? A. Hearing will not be affected by a decibel level in this range. B. Hearing loss may occur with a decibel level in this range. C. Sounds in this decibel level are not perceived to be harsh to the ear. D. Ear plugs will have no effect on these decibel levels.

A hospitalized client with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the client's room? A. That a commode is always available at the bedside B. That all furniture remains in the same position C. That visitors do not leave items on the bedside table D. That the client's slippers stay under the bed

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache? A. As soon as the client's pain becomes unbearable B. As soon as the client senses the onset of symptoms C. Twenty to 30 minutes after the onset of symptoms D. When the client senses his or her symptoms peaking

A nurse is planning preoperative teaching for a client with hearing loss due to otosclerosis. The client is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the client's preoperative teaching? A. The procedure is an effective, time-tested treatment for sensory hearing loss. B. The client is likely to experience resolution of conductive hearing loss after the procedure. C. Several months of postprocedure rehabilitation will be needed to maximize benefits. D. The procedure is experimental, but early indications suggest great therapeutic benefits.

A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placement B. Supplemental oxygen and monitoring blood glucose levels C. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? A. "We are trying to help the client be as useful as possible." B. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." C. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." D. "Rehabilitation means helping clients do exactly what they did before their stroke."

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A. Generalized seizure B. Absence seizure C. Focal seizure D. Unclassified seizure

During discharge teaching the nurse realizes that the client is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene? A. Ask the social worker to investigate alternative housing arrangements. B. Ask the social worker to investigate community support agencies. C. Encourage the client to explore surgical corrections for the vision problem. D. Arrange for referral to a rehabilitation facility for vision training.

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect should the nurse assess this client? A. Pruritus B. Dyskinesia C. Lactose intolerance D. Diarrhea

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client supine. B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. C. Position client in prone position. D. Maintain bed in Trendelenburg position.

The nurse in an extended care facility is planning the daily activities of a client with post-polio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time? A. Immediately after meals B. In the morning C. Before bedtime D. In the early evening

The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the client's ADLs, what goal should the nurse prioritize? A. Promoting the client's recovery from the disease B. Maximizing the client's level of function C. Ensuring the client's adherence to treatment D. Fostering the family's participation in care

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

The nurse is caring for a client who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement? A. Teach the client about the risks of ototoxic medications. B. Instruct the client to protect the ear from water for several weeks. C. Teach the client to remove cerumen safely at least once per week. D. Instruct the client to protect the ear from temperature extremes until healing is complete.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? A. Intravenous phenobarbital B. Intravenous diazepam C. Oral lorazepam D. Oral phenytoin

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? A. Change the client's position as indicated. B. Monitor serum electrolytes. C. Maintain NPO status. D. Monitor arterial blood gas (ABG) values.

The nurse is caring for a client who is scheduled for a cervical discectomy the following day. During health education, the client should be made aware of what potential complications? A. Vertebral fracture B. Hematoma at the surgical site C. Scoliosis D. Renal trauma

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once daily B. Resting in an air-conditioned room whenever possible C. Increasing the dose of muscle relaxants D. Avoiding naps during the day

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A. Tinnitus B. Facial paralysis C. Pain at the base of the tongue D. Diplopia

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? A. Computed tomography (CT) scan B. Lumbar puncture C. Magnetic resonance imaging (MRI) D. Venous Doppler studies

The nurse is planning the care of a client who is adapting to the use of a hearing aid for the first time. What is the most significant challenge this client is likely to experience? A. Regulating the tone and volume B. Learning to cope with amplification of background noise C. Constant irritation of the external auditory canal D. Challenges in keeping the hearing aid clean while minimizing exposure to moisture

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

The nurse is providing health education to a client diagnosed with glaucoma. The nurse teaches the client that this disease has a familial tendency. The nurse knows that clinical examinations for family members at risk for glaucoma should occur how often? A. At least monthly B. At least once every 2 years C. At least once every 5 years D. At least once every 10 years

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? A. Potassium-sparing diuretics B. Cholinergics C. Antibiotics D. Loop diuretics

The nurse's assessment of a client with significant visual losses reveals that the client cannot count fingers. How should the nurse proceed with assessment of the client's visual acuity? A. Assess the client's vision using a Snellen chart. B. Determine whether the client is able to see the nurse's hand motion. C. Perform a detailed examination of the client's external eye structures. D. Palpate the client's periocular regions.

To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment? A. Concurrent use of calcium supplements is contraindicated. B. Blood levels of the drug must be monitored. C. The drug is likely to cause hyperactivity and agitation. D. Carbamazepine can cause tinnitus during the first few days of treatment.

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit? A. Recent completion of radiation therapy for treatment of thyroid cancer B. Routine use of quinine for management of leg cramps C. Allergy to hair coloring and hair spray D. Previous perforation of the eardrum

A nurse is preparing a presentation for a group of elementary school parents about ways to promote the health of the ears and hearing in their children. When describing the structure and function of the ears, which structure would the nurse most likely include as part of the middle ear? Select all that apply. A. pinna B. tympanic membrane C. oval window D. cochlea E. organ of Corti

B,C

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice. B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's discharge E. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

B,C

A 69-year-old client is brought to the ED by ambulance because a family member found the client lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. A. Obtain a blood type and cross-match. B. Administer antipyretics as prescribed. C. Perform frequent neurologic assessments. D. Monitor pain levels and administer analgesics. E. Place the client in positive pressure isolation.

B,C,D

33. When administering a client's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A. Ensure that the client is well hydrated at all times. B. Encourage self-administration of eye drops. C. Occlude the puncta after applying the medication. D. Position the client supine before administering eye drops.

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B. Flexor spasm, clonus, and negative Babinski reflex C. Blurred vision, intention tremor, and urinary hesitancy D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

A 48-year-old client has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A. The client will likely require lifelong treatment with anticholinergic medications. B. The client has a disproportionate risk of developing myasthenia gravis later in life. C. The client needs to be assessed for MS. D. The disease is self-limiting and the client will achieve pain relief over time.

A 56-year-old client has come to the clinic for a routine eye examination and is told bifocals are needed. The client asks the nurse what change in the eyes has caused this need for bifocals. How should the nurse respond? A. "You know, you are getting older now and we change as we get older." B. "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry." C. "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." D. "The eye gets shorter, back to front, as we age and it changes how we see things."

A 6-month-old infant is brought to the ED by the parents for inconsolable crying and pulling at the right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear? A. Yellowish-white B. Pink C. Gray D. Bluish-white

A child goes to the school nurse and reports being unable to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? A. Audiometry B. Rinne test C. Whisper test D. Weber test

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic stroke B. Risk factors for ischemic stroke C. How to correctly modify the home environment D. Techniques for adjusting the client's medication dosages at home

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

A client has been diagnosed with hearing loss related to damage of the cochlea. What term is used to describe this condition? A. Exostoses B. Otalgia C. Sensorineural hearing loss D. Presbycusis

A client has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this client's health status? A. For some clients, these recurrent infections constitute an age-related physiologic change. B. The client would benefit from a temporary mobility restriction to facilitate healing. C. The client needs to be assessed for nasopharyngeal cancer. D. Blood cultures should be drawn to rule out a systemic infection.

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Unclassified seizure B. Absence seizure C. Generalized seizure D. Focal seizure

A client has informed the home health nurse that he/she has recently noticed distortions when looking at the Amsler grid that is mounted on the refrigerator. What is the nurse's most appropriate action? A. Reassure the client that this is an age-related change in vision. B. Arrange for the client to have his/her visual acuity assessed. C. Arrange for the client to be assessed for macular degeneration. D. Facilitate tonometry testing.

A client has just arrived to the floor after an enucleation procedure following a workplace accident in which the client's left eye was irreparably damaged. Which of the following should the nurse prioritize during the client's immediate postoperative recovery? A. Teaching the client about options for eye prostheses B. Teaching the client to estimate depth and distance with the use of one eye C. Assessing and addressing the client's emotional needs D. Teaching the client about his postdischarge medication regimen

A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A. Serial assessments of hemoglobin levels B. Blood glucose monitoring C. Close monitoring of fluid balance D. Assessment of pain along dermatomes

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? A. Hydrochlorothiazide B. Furosemide C. Mannitol D. Spironlactone

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's reported headache? A. Initiating a client-controlled analgesia (PCA) of morphine sulfate B. Administering hydromorphone IV as needed C. Dimming the lights and reducing stimulation D. Distracting the client with activity

A client is being discharged home after mastoid surgery. What topic should the nurse address in the client's discharge education? A. Expected changes in facial nerve function B. The need for audiometry testing every 6 months following recovery C. Safe use of analgesics and antivertiginous agents D. Appropriate use of over-the-counter (OTC) ear drops

A client is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the client may have required surgery on what neurologic structure? A. Cerebellum B. Hypothalamus C. Pituitary gland D. Pineal gland

A client who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the client's vomiting is most consistent with a brain tumor? A. The client's vomiting is accompanied by epistaxis. B. The client's vomiting does not relieve his nausea. C. The client's vomiting is unrelated to food intake. D. The client's emesis is blood-tinged.

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? A. Monitoring of pulse oximetry B. Administration of a low-protein diet C. Administration of thorough oral hygiene D. Fluid restriction as prescribed

A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A. Administer bronchodilators as ordered. B. Remind the client of the importance of deep breathing and coughing exercises. C. Prepare to assist with intubation. D. Administer supplementary oxygen by nasal cannula.

A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client reports achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond? A. "It's important to drink plenty of fluids while you're taking laxatives." B. "Make sure that you supplement your laxatives with a nutritious diet." C. "Let's explore other options, because laxatives can have side effects and create dependency." D. "You should ideally be using herbal remedies rather than medications to promote bowel function."

A client with Parkinson disease is undergoing a swallowing assessment because the client has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? A. Total parenteral nutrition (TPN) B. Provision of a low-residue diet C. Semisolid food with thick liquids D. Minced foods and a fluid restriction

A client with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? A. Assessment of peripheral nervous function B. Assessment of cranial nerve function C. Assessment of nutritional status D. Assessment of respiratory status

A client with a history of epilepsy is admitted preoperatively for a surgical procedure and dies overnight. The health care provider suspects sudden unexpected death in epilepsy (SUDEP). Which condition is most likely related to SUDEP? A. Brain aneurysm B. Undiagnosed sepsis C. Cardiac abnormalities D. Seizure medication overdose

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. D. The client sits up and turns to one side to see the object and states what is needed.

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition? A. Chronic confusion B. Impaired urinary elimination C. Impaired verbal communication D. Bowel incontinence

A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A. Encephalitis B. Cerebral spinal fluid leak C. Meningitis D. Catheter occlusion

A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? A. Metastasis B. Risk for stroke C. Emotional and personality changes D. Pathologic bone fracture

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasia C. Agnosia D. Hemiplegia

A nurse is planning the care of a 28-year-old client hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? A. All at one time, to provide a longer rest period B. Before meals, to stimulate the client's appetite C. In the morning, with frequent rest periods D. Before bedtime, to promote rest

An older adult client has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the client for recent changes in visual acuity, the client states that the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response? A. Ask if the client has been using OTC vasoconstrictors. B. Instruct the client to repeat the test at different times of the day when at home. C. Arrange for the client to visit an ophthalmologist . D. Encourage the client to adhere to prescribed drug regimen.

Cytomegalovirus (CMV) is the most common cause of retinal inflammation in clients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis? A. Pilocarpine B. Penicillin C. Ganciclovir D. Gentamicin

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of this diagnosis? A. Tophi on the pinna and ear lobe B. Dark yellow cerumen in the external auditory canal C. Pain on manipulation of the auricle D. Air bubbles visible in the middle ear

The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? A. Suctioning secretions B. Facilitating ABG analysis C. Providing ventilatory assistance D. Administering tube feedings

The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A. Maintaining the client's functional independence B. Providing health education C. Monitoring neurologic status closely D. Promoting mobility

The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma? A. The client uses over-the-counter NSAIDs. B. The client has a history of stroke. C. The client has diabetes. D. The client has Asian ancestry.

The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position. B. The client should be in a supine position unless ambulating. C. The client should be placed in a prone position for 15 to 30 minutes several times a day. D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A. Position the client the high Fowler position as tolerated. B. Administer osmotic diuretics as prescribed. C. Participate in interventions to increase cerebral perfusion pressure (CPP). D. Prepare the client for craniotomy.

The nurse is caring for a client newly diagnosed with a primary brain tumor. The client asks the nurse where the tumor came from. What would be the nurse's best response? A. "Your tumor originated from somewhere outside the CNS." B. "Your tumor likely started out in one of your glands." C. "Your tumor originated from cells within your brain itself." D. "Your tumor is from nerve tissue somewhere in your body."

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? A. Solumedrol B. Dextromethorphan C. Dexamethasone D. Furosemide

The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury? A. Avoid watching television or using a computer for more than 1 hour at a time. B. Use over-the-counter antibiotic eye drops for at least 14 days. C. Avoid rubbing the eye on the affected side of the face. D. Rinse the eye on the affected side with normal saline daily for 1 week.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation

The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care? A. Risk for disturbed sensory perception B. Risk for unilateral neglect C. Risk for falls D. Risk for ineffective health maintenance

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge.

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? A. Naproxen 250 PO b.i.d. B. Calcium carbonate 1,000 mg PO b.i.d. C. Aspirin 81 mg PO o.d. D. Lorazepam 1 mg SL b.i.d. PRN

The nurse is teaching a client to care for a new ocular prosthesis. What should the nurse emphasize during the client's health education? A. The need to limit exposure to bright light B. The need to maintain a low Fowler position when removing the prosthesis C. The need to perform thorough hand hygiene before handling the prosthesis D. The need to apply antiviral ointment to the prosthesis daily

The nurse is writing a care plan for a client with brain metastases. The nurse decides that an appropriate nursing diagnosis is "anxiety related to lack of control over the health circumstances." In establishing this plan of care for the client, the nurse should include which intervention? A. Antianxiety medications every 4 hours B. Family instruction on planning the client's care C. Encouragement to verbalize concerns related to the disease and its treatment D. Intensive therapy with the goal of distraction

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps. Place the steps in the order in which they occur. All options must be used. 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated A. 635241 B. 352416 C. 236145 D. 162534

A nurse is reading a journal article about brain tumors and the various types that can occur. The nurse demonstrates understanding of the article by identifying which type as being classified as an intracerebral tumor? Select all that apply. A. meningioma B. schwannoma C. glioblastoma D. astrocytoma E. medulloblastoma

C,D,E

The nurse is caring for a client with a brain tumor who is experiencing symptoms due to compression and infiltration of normal tissue. The pathophysiologic changes that result can cause what manifestations? Select all that apply. A. Intracranial hemorrhage B. Infection of cerebrospinal fluid C. Increased ICP D. Focal neurologic signs E. Altered pituitary function

C,D,E

An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this client be taught about this diagnosis? Select all that apply. A. Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B. Cholesteatomas are usually the result of metastasis from a distant tumor site. C. Cholesteatomas are often the result of chronic otitis media. D. Cholesteatomas, if left untreated, result in intractable neuropathic pain. E. Cholesteatomas usually must be removed surgically.

C,E

A 37-year-old client is brought to the clinic by the spouse because the client is experiencing loss of motor function and sensation. The health care provider suspects the client has a spinal cord tumor and hospitalizes the client for diagnostic testing. In light of the need to rule out spinal cord compression from a tumor, the nurse will most likely prepare the client for what test? A. Anterior-posterior x-ray B. Ultrasound C. Lumbar puncture D. MRI

A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing? A. Cranial arteritis B. Cluster headache C. Paroxysmal hemicranias D. Secondary headache

A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client? A. Older adults are often vague historians. B. Older adults have fewer peripheral nerves than younger adults. C. Many older adults are hesitant to admit that their body is changing. D. Many symptoms can be the result of normal aging process.

A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? A. Ossiculoplasty B. Insertion of a cochlear implant C. Stapedectomy D. Insertion of a ventilation tube

A client diagnosed with Bell palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A. Blowing up balloons B. Deliberately frowning C. Smiling repeatedly D. Whistling

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A. Hemiplegia B. Dry mucous membranes C. Signs of internal bleeding D. Loss of brain stem reflexes

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family? A. Risk for infection B. Impaired spontaneous ventilation C. Unilateral neglect D. Risk for injury

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? A. Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B. Eyeglasses or magnifying lenses C. Corticosteroid eye drops D. Surgical intervention

A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding? A. "I need to call the doctor if I get nauseated." B. "I need to call the doctor if I have a light morning discharge." C. "I need to call the doctor if I get a scratchy feeling." D. "I need to call the doctor if I see flashing lights."

A client presents at the clinic with pain and weakness in the hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what condition? A. Guillain-Barré syndrome B. Myasthenia gravis C. Trigeminal neuralgia D. Peripheral nerve disorder

A client presents to the ED reporting a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The client mentions to the nurse experiencing a sudden hearing loss. What would the nurse suspect the client's diagnosis will be? A. Ossiculitis B. Ménière disease C. Ototoxicity D. Labyrinthitis

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment

A client with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A. Risk factors for postoperative cytomegalovirus (CMV) B. Compensating for vision loss for the next several weeks C. Nonpharmacologic pain management strategies D. Signs and symptoms of increased intraocular pressure

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Restrain the client to prevent injury. B. Open the client's jaws to insert an oral airway. C. Place client in high Fowler position. D. Loosen the client's restrictive clothing.

A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action? A. Intubation B. STAT computed tomography (CT) health care provider C. A STAT MRI D. Administration of anticonvulsants

A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobe C. Central sulcus D. Penumbra region

A client with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the client administers the pilocarpine, the client states that the client's vision is blurred. Which nursing action is most appropriate? A. Holding the next dose and notifying the health care provider B. Treating the client for an allergic reaction C. Suggesting that the client put on her glasses D. Explaining that this is an expected adverse effect

A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client? A. Cerebral angiography B. ABG analysis C. CT D. EEG

A client, diagnosed with cancer of the lung, has just been told the cancer has metastasized to the brain. What change in health status would the nurse attribute to the client's metastatic brain disease? A. Chronic pain B. Respiratory distress C. Fixed pupils D. Personality changes

A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? A. Cognitive declines B. Personality changes C. Contractures D. Difficulty in coordination

A nurse is assisting the ophthalmologist who is performing direct ophthalmoscopy. When conducting this examination, which structure would the nurse expect to be examined last? A. red reflex B. vasculature C. optic disc D. macula

A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke? A. Occurs with vascular occlusion. B. Is also known as thrombotic stroke. C. Can be known as lacunar strokes. D. Can occur in the subarachnoid space.

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A. Rinsing the ears with normal saline after swimming B. Avoiding loud environmental noises C. Instilling antibiotic ointments on a regular basis D. Avoiding the use of cotton swabs

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? A. Adult failure to thrive B. Post-trauma syndrome C. Hyperthermia D. Disturbed sensory perception

After mastoid surgery, an 81-year-old client has been identified as needing assistance in her home. What would be a primary focus of this client's home care? A. Preparation of nutritious meals and avoidance of contraindicated foods B. Ensuring the client receives adequate rest each day C. Helping the client adapt to temporary hearing loss D. Assisting the client with ambulation as needed to avoid falling

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A. It suggests onset of metabolic problems. B. It indicates paralysis on the right side of the body. C. It indicates paralysis of cranial nerve X (CN X). D. It indicates an injury at the midbrain level.

Following a motorcycle accident, an adolescent client is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A. The malleus can be visualized during otoscopic examination. B. The tympanic membrane is pearly gray. C. Tenderness is reported by the client when the mastoid area is palpated. D. Clear, watery fluid is draining from the client's ear.

Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A. Arrange for the administration of prophylactic antibiotics to unaffected residents. B. Instill normal saline into the eyes of affected residents two to three times daily. C. Swab the conjunctiva of unaffected residents for culture and sensitivity testing. D. Isolate affected residents from residents who have not developed conjunctivitis.

The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? A. Impaired skin integrity B. Cognitive deficits C. Hemorrhage D. Autonomic dysfunction

The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye? A. 30 seconds B. 1 minute C. 3 minutes D. 5 minutes

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? A. Prednisone B. Dexamethasone C. Cafergot D. Phenytoin

The nurse is caring for a client with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the client's plan of care? A. Firmly redirect the client's head when feeding. B. Administer phenothiazines after each meal as prescribed. C. Encourage the client to keep his or her feeding area clean. D. Apply deep, gentle pressure around the client's mouth to aid swallowing

The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A. Encourage the client to void every hour. B. Order a low-residue diet. C. Provide total assistance with all ADLs. D. Instruct the client on daily muscle stretching.

The nurse is discharging a client home after mastoid surgery. What should the nurse include in discharge teaching? A. "Try to induce a sneeze every 4 hours to equalize pressure." B. "Be sure to exercise to reduce fatigue." C. "Avoid sleeping in a side-lying position." D. "Don't blow your nose for 2 to 3 weeks."

The nurse is preparing to provide care for a client diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what issue? A. Genetic dysfunction B. Upper and lower motor neuron lesions C. Decreased conduction of impulses in an upper motor neuron lesion D. A lower motor neuron lesion

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A. The ability of the client to follow instructions during the seizure. B. The success or failure of the care team to physically restrain the client. C. The client's ability to explain his seizure during the postictal period. D. The client's activities immediately prior to the seizure.

The nurse is reviewing the health history of a newly admitted client and reads that the client has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the client's plan of care? A. The nurse should perform the Rinne and Weber tests. B. The nurse should arrange for audiometry testing as soon as possible. C. The nurse should collaborate with the pharmacist to assess for potential ototoxic medications. D. No specific assessments or interventions are necessary to address exostoses.

The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease? A. Intermittent hearing loss B. Tinnitus C. Tongue enlargement D. Vocal paralysis

The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? A. "I'm planning to avoid exposure to direct sunlight on my next vacation." B. "I've never exercised regularly, but I'm going to start working out at the gym daily." C. "I'm planning to talk with my pharmacist to review my current medications." D. "I'm certainly going to keep a close eye on my blood pressure from now on."

The registered nurse taking shift report learns that an assigned client is blind. How should the nurse best communicate with this client? A. The nurse should provide instructions in simple, clear terms. B. Using a loud voice, the nurse should offer an introduction while in the doorway of the room. C. Lightly touch the client's arm and then say the nurse's name . D. The nurse should state the nurse's name and role immediately after entering the client's room.

Upon examination via otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis? A. Acoustic tumor B. Cholesteatoma C. Facial nerve neuroma D. Glomus tympanicum

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day. B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A. Cushing syndrome B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Adrenal crisis D. Diabetes insipidus

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A. Ensure that clients understand the differences between sensory hearing loss and conductive hearing loss. B. Educate clients about expected age-related changes in hearing perception. C. Educate clients about the risks associated with prolonged exposure to environmental noise. D. Be aware of clients' medication regimens and collaborate with other professionals accordingly.

A nurse is conducting an examination of a client's inner eye. When viewing the retina, which structure(s) would the nurse identify as a retinal landmark? Select all that apply. A. optic disk B. macula C. posterior chamber D. vitreous humor E. ciliary body

A,B

A client is diagnosed with an acoustic neuroma. When assessing this client, which manifestation would the nurse expect to find? Select all that apply. A. tinnitus B. vertigo C. staggering gait D. seizures E. headache

A,B,C

32. A client has become legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate? A. Encourage the client to focus on use of other senses. B. Assess and promote the client's coping skills during interactions with the client. C. Emphasize that lifestyle will be unchanged once adaptation to vision loss has occurred. D. Promote the client's hope for recovery.

Med Surg Exam 4 TB

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