Med Surg Test 2 Review questions
The nurse educates a patient who has undergone prostate surgery about health promotion measures to be followed at home. Which statement made by the patient indicates the need for further teaching? 1 "I am limiting fluid intake." 2 "I am limiting citrus juices." 3 "I am avoiding heavy lifting." 4 "I am avoiding sexual intercourse."
"I am limiting fluid intake." Limiting fluid intake can cause constipation and infection in a patient who has undergone prostate surgery; fluid intake should not be limited. The patient should limit citrus juices because they can cause urinary incontinence. Heavy lifting puts stress on stitches and can cause bleeding; that activity should be avoided. The patient should avoid intercourse for a few days to avoid straining the abdominal muscles.
The nurse is discussing glaucoma prevention with a 52-year-old African American patient. Which statement by the patient reflects a correct understanding of glaucoma prevention? 1 "I will visit my eye doctor every one to two years." 2 "I will wear protective sunglasses while outside." 3 "I will take lutein and vitamin E supplements for eye health." 4 "There is nothing that can be done to prevent vision loss from glaucoma."
"I will visit my eye doctor every one to two years." The nurse is discussing glaucoma prevention with a 52-year-old African American patient. Which statement by the patient reflects a correct understanding of glaucoma prevention?
A patient asks the nurse about rapid testing for human immunodeficiency virus (HIV) infection at home. What is the best response by the nurse? 1 "These tests are done on freshly voided urine." 2 "Positive rapid tests should be repeated for confirmation." 3 "Rapid tests are screening tests for antibodies, not for antigens." 4 "These tests are not recommended by the Centers for Disease Control and Prevention (CDC)."
"Rapid tests are screening tests for antibodies, not for antigens." Rapid testing is recommended strongly by the CDC and can be done in a variety of settings. These tests are screening tests for antibodies, not antigens; testing is done on oral fluid samples. Positive rapid tests need to be confirmed with the more specific Western blot (WB) or immunofluorescence assay (IFA). This step necessitates a blood draw and a return appointment to get results.
The nurse is educating a patient that has human immunodeficiency virus (HIV) about monitoring for the development of opportunistic diseases. What statement made by the patient demonstrates an understanding of the education provided? 1 "These diseases are usually benign." 2 "Opportunistic diseases are not treatable if they occur." 3 "They don't usually occur in people with healthy immune systems." 4 "Opportunistic diseases only occur at the end stages of HIV infection."
"They don't usually occur in people with healthy immune systems." Opportunistic diseases generally do not occur in the presence of a functioning immune system. Organisms that do not cause severe disease in people with functioning immune systems can cause debilitating, disseminated, and life-threatening infections during this stage. Several opportunistic diseases may occur at the same time, compounding the difficulties of diagnosis and treatment. Advances in HIV treatment have decreased the occurrence of opportunistic diseases. These diseases can occur early in the process of HIV infection and sometimes are used to diagnose the presence of HIV.
A patient had an intradermal tuberculin skin test (Mantoux) administered 48 hours ago. The nurse assesses the injection site and identifies a 12-mm area of palpable induration. How should the nurse interpret this result? 1 Definitive evidence that the patient does not have tuberculosis 2 A significant indication that the patient has been exposed to tuberculosis 3 Delayed hypersensitivity with a high likelihood of infection with tuberculosis 4 A negative test that cannot be interpreted as ruling out the presence of tuberculosis
A significant indication that the patient has been exposed to tuberculosis An area of 12 mm of induration at the injection site 48 hours after a Mantoux test is considered significant for a past or current tuberculin infection. An induration of less than 5 mm is considered a negative result. The other answer options are incorrect conclusions related to the findings.
A nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. The sputum, which is yellow, has been sent for laboratory testing, but the lab report is pending. What should be the next step in managing the patient? 1 Administer antibiotics. 2 Wait for the lab report. 3 Refer the patient for chest physiotherapy. 4 Retake sputum sample and send to another lab.
Administer antibiotics. Culture and Gram stain of sputum is required for prescribing specific antibiotics. However, if there is a delay in obtaining the lab reports, antibiotic administration should not be delayed. Deferring the antibiotics may lead to increased morbidity and mortality because the infection can worsen. Taking the sample again to send to a different lab would not be helpful because the lab will take a similar amount of time to provide the report. Chest physiotherapy can be advised later once the antibiotic therapy is started.
A patient is being provided with discharge instructions after undergoing cataract extraction and intraocular lens implantation. What should the nurse include in the teaching? 1 Avoid straining during bowel movements. 2 Keep consuming a full-liquid diet for 24 hours. 3 Refrain from reading or watching TV for at least 12 hours. 4 Keep a patch over the affected eye until the follow-up appointment with the surgeon.
After cataract surgery, coughing, bending at the waist, and straining during bowel movements should be avoided because these activities increase intraocular pressure. It is not necessary to maintain dietary restrictions, refrain from reading or watching TV, or wear a patch.
The patient with breast cancer has a left mastectomy with axillary node dissection. Ten lymph nodes are resected, with three positive for malignant cells. The patient has stage IIB breast cancer. What is the best nursing intervention to use in planning care? 1 Evaluate left arm lymphatic accumulation. 2 Maintain joint flexibility and left arm function. 3 Teach the patient about chemotherapy and radiation therapy. 4 Assess the patient's response to the diagnosis of breast cancer.
Assess the patient's response to the diagnosis of breast cancer. Assessment is the first step in planning patient care. Because the nurse is the patient's advocate and this is an extremely stressful time for the patient and family, the nurse should focus on the patient's response to the diagnosis of breast cancer when planning care for this patient. The approach for the care of the left arm and teaching the patient about further therapy will be based on this assessment.
A nurse teaching a community group about ways to reduce the risk for colorectal cancer includes decreasing the dietary intake of: 1 Beef and pork 2 Fish and poultry 3 Fresh and dried fruits 4 Green leafy vegetables
Beef and pork Development of colorectal cancer has been associated with consumption of a high-fat diet. Of the foods listed, beef and pork are the highest in fat content. A diet that includes plenty of fresh fruits, vegetables, fish, and poultry is best for reducing the risk of colorectal and other forms of cancer.
The nurse is caring for a patient suspected of having age-related macular degeneration. What symptoms should the nurse document and report regarding this disorder? 1 Blurred, darkened vision 2 Itching, burning, and redness 3 Sudden, excruciating pain in the eye 4 Decreased vision, abnormal color perception
Blurred, darkened vision Age-related macular degeneration (AMD) is an eye condition that leads to the deterioration of the center of the retina, called the macula, leading to loss of central vision. The patient with AMD has blurred and darkened vision, scotomas, and metamorphopsia. The symptoms of cataract are decreased vision, abnormal color perception, and glare. The symptoms of glaucoma are sudden, excruciating pain in or around the eye. The symptoms of allergic conjunctivitis are itching, burning, and redness.
The family of a patient with newly diagnosed tuberculosis is tested for infection with Mycobacterium tuberculosis. The patient's wife, who has a history of alcoholism, has had two negative Mantoux (PPD) tests. Both of their children have positive Mantoux results. The nurse recognizes that a course of preventive treatment with isoniazid will be required for which family member(s)? 1 The spouse only 2 Both children only 3 The spouse and the children 4 Neither the spouse nor the children
Both children only The children would be given isoniazid (INH) because of exposure and conversion from a negative to a positive Mantoux result. The wife would not be treated because she has not converted to positive and may be susceptible to INH hepatitis, a susceptibility that increases with age. She may also be susceptible to hepatotoxicity because of her age and history of alcoholism. The children definitely require preventive treatment with INH.
When teaching patients with prostate cancer about brachytherapy, which information should the nurse include? Select all that apply. 1 Brachytherapy is a one-time outpatient procedure. 2 Brachytherapy can cause damage to the bladder and rectum. 3 Brachytherapy is best suited for patients with early stage disease. 4 Brachytherapy is advantageous because it preserves erectile function. 5 Brachytherapy has side effects that include urinary irritative or obstructive problems.
Brachytherapy is a one-time outpatient procedure. Brachytherapy is best suited for patients with early stage disease. Brachytherapy has side effects that include urinary irritative or obstructive problems. Brachytherapy is a one-time outpatient procedure, and the side effects include urinary irritative or obstructive problems. Brachytherapy is best suited for patients with early stage disease, because the procedure involves placing radioactive seed implants into the prostate gland, allowing higher radiation doses directly in the tissue while sparing the surrounding tissue. Brachytherapy is specifically designed to protect surrounding tissues such as the bladder and rectum. The procedure can, however, cause erectile dysfunction.
The nurse is caring for a patient who had a laparotomy one day ago and has a nasogastric tube in place. During suctioning of the nasogastric tube, the nurse finds that the nasogastric aspirate has become bright red in color. What action should the nurse take first? 1 Notify the surgeon. 2 Administer intravenous (IV) fluids. 3 Continue suctioning the aspirate. 4 Flush the nasogastric tube with normal saline.
Bright red color in the aspirate indicates ongoing hemorrhage. The surgeon should be notified immediately. Administering IV fluids and suctioning can be done once the surgeon is notified. Flushing the nasogastric tube with normal saline is not advised.
The nurse is caring for a patient newly diagnosed with human immunodeficiency virus (HIV). The patient asks what would determine the actual development of acquired immunodeficiency syndrome (AIDS). The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? 1 Presence of HIV antibodies 2 CD4 +T cell count below 200/µL 3 Presence of oral hairy leukoplakia 4 White blood cell (WBC) count below 5000/µL
CD4 +T cell count below 200/µL Diagnostic criteria for AIDS include a CD4 +T cell count below 200/µL or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The presence of HIV antibodies or oral hairy leukoplakia or WBC count below 5000/µL may be found in patients with HIV disease, but do not define the advancement of HIV infection to AIDS.
During an assessment, the nurse finds that a patient who is HIV-positive has whitish yellow patches in the mouth, GI tract, and esophagus. Which opportunistic infection is the patient likely experiencing? 1 Candida albicans 2 Coccidioides immitis 3 Cryptosporidium muris 4 Cryptococcus neoformans
Candida albicans Opportunistic infections are caused by microorganisms that normally do not cause disease but which become pathogenic when the immune system is impaired and unable to fight off infection. AIDS patients are susceptible to opportunistic diseases. Whitish yellow patches in mouth, GI tract, and esophagus and the presence of thrush indicate Candida albicans. Infection by Coccidioides immitis manifests with symptoms like pneumonia, fever, weight loss, and cough. Cryptosporidium muris gastroenteritis is characterized by watery diarrhea, abdominal pain, and weight loss. Meningitis, cognitive impairment, motor dysfunction, fever, seizures, and headache are symptoms of Cryptococcus neoformans.
A patient is diagnosed with acquired immunodeficiency syndrome (AIDS). Which opportunistic infections should the nurse monitor for in the patient? Select all that apply. 1 Legionnaires' disease 2 Candidiasis of bronchi 3 Ebola hemorrhagic fever 4 Toxoplasmosis of the brain 5 Mycobacterium avium (MAC) complex
Candidiasis of bronchi Toxoplasmosis of the brain Mycobacterium avium (MAC) complex Candidiasis of bronchi, toxoplasmosis of the brain, and Mycobacterium avium complex are opportunistic infections in AIDS, because the immune system is too weak to fight back. Candidiasis of the bronchi is a fungal infection caused by Candida albicans. It rarely causes problems in healthy adults because they have strong immune systems, but is common in people with HIV due to weakened immunity. Toxoplasmosis of the brain is a protozoal infection, and Mycobacterium avium complex is a bacterial infection. Ebola hemorrhagic fever is caused by Ebola virus, and Legionnaires' disease is caused by Legionella pneumophila; these are not opportunistic diseases. They are emerging infections that have recently increased in incidence.
A patient presenting with pneumonia scores 5 on the CURB-65 scale. What action should the nurse take? 1 Advise no treatment. 2 Advise treating at home. 3 Consider hospital admission. 4 Consider admission to an intensive care unit.
Consider admission to an intensive care unit. CURB-65 is used in addition to clinical judgment in determining the severity of pneumonia and the need for advanced medical care. A patient scoring 5 on the CURB-65 scale means the condition is severe and needs advanced medical care. Hence, the nurse should consider admission to an intensive care unit. If the patient has symptoms of pneumonia, advising no treatment is not an option. Treating at home is advised when the score on CURB-65 scale is 0. Hospital admission is considered when the score on the CURB-65 scale is 1 to 2.
A patient with human immunodeficiency virus (HIV) is educated about health promotion activities. What should the nurse inform the patient the importance of these activities is? 1 Delaying disease progression 2 Preventing disease transmission 3 Helping to cure the HIV infection 4 Enabling an increase in self-care activities
Delaying disease progression These health promotion activities, along with mental health counseling, support groups, and a therapeutic relationship with health care providers, will promote a healthy immune system, which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities.
The nurse is monitoring a patient who has pneumonia with thick secretions. The patient is having difficulty clearing the secretions. Which of these would be appropriate nursing interventions for this patient? Select all that apply. 1 Perform postural drainage every hour. 2 Encourage the patient to rest and limit activity. 3 Provide adequate hydration by encouraging fluid intake. 4 Provide analgesics as prescribed to promote patient comfort. 5 Teach the patient how to cough effectively to bring secretions to the mouth.
Encourage the patient to rest and limit activity. Provide adequate hydration by encouraging fluid intake. Teach the patient how to cough effectively to bring secretions to the mouth. Interventions for pneumonia include teaching the patient how to cough effectively to remove secretions, providing adequate hydration, and encouraging rest. Hydration is important in the supportive treatment of pneumonia to prevent dehydration and loosen secretions. Individualize and carefully monitor fluid intake if the patient has heart failure. It is not necessary to provide postural drainage every hour. Providing analgesics will not help the patient clear secretions.
When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, on what should the nurse focus? 1 Giving anticipatory guidance about the eventual loss of central vision that will occur 2 Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision 3 Recognizing that eye damage caused by glaucoma can be reversed in the early stages 4 Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies
Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Drug therapy is necessary to prevent the eventual vision loss that may occur as a consequence of glaucoma. For this reason, the patient should be encouraged to remain compliant with drug therapy. Glaucoma cannot be reversed. Central vision usually is unaffected with open-angle glaucoma. Pain management is important throughout the course of the disease.
A patient was diagnosed with human immunodeficiency virus (HIV) approximately 12 years ago. The nurse recognizes that which assessment findings are diagnostic of acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1 Typhoid fever 2 Hepatitis A infection 3 Esophageal candidiasis 4 Pulmonary cryptococcosis 5 CD4 count less than 200 cells/µL
Esophageal candidiasis CD4 count less than 200 cells/µL To diagnose AIDS, the patient should have an opportunistic infection such as esophageal candidiasis, or the CD4 count should be less than 200 cells/µL of blood.
While obtaining a health history for a patient with suspected tuberculosis, the nurse expects the patient to report which signs or symptoms? Select all that apply. 1 Fever 2 Fatigue 3 Dyspnea 4 Night sweats 5 Chest tightness
Fever Fatigue Night sweats The patient with tuberculosis presents with night sweats, fatigue, and fever. Chest tightness and dyspnea are not present in the patient with tuberculosis.
A patient with pneumonia is being treated at home and has reported fatigue to the nurse. What instructions should the nurse include when teaching the patient about care and recovery at home? Select all that apply. 1 Get adequate rest. 2 Restrict fluid intake. 3 Avoid alcohol and smoking. 4 Resume work to build strength. 5 Take every dose of the prescribed antibiotic.
Get adequate rest. Avoid alcohol and smoking. Take every dose of the prescribed antibiotic. To ensure complete recovery after pneumonia, the patient should be advised to rest, avoid alcohol and smoking, and take every dose of the prescribed antibiotic. The patient should not resume work if feeling fatigued and should be encouraged to drink plenty of fluids during the recovery period.
A patient asks the nurse, "How does glaucoma damage my eyesight?" What explanation should the nurse provide to the patient? 1 Glaucoma leads to detachment of the retina. 2 Glaucoma results from chronic eye inflammation. 3 Glaucoma results in increased intraocular pressure. 4 Glaucoma is caused by decreased blood flow to the retina.
Glaucoma results in increased intraocular pressure. In chronic open-angle glaucoma the outflow of aqueous humor is obstructed, leading to increased intraocular pressure. The increased intraocular pressure eventually causes destruction of the nerve fibers of the retina and painless vision loss, beginning in the periphery. Glaucoma does not cause detachment of the retina, result from chronic inflammation, or result from decreased retinal blood flow.
To ease pleuritic pain caused by pneumonia, what nursing interventions should be performed? 1 Instructing the patient to splint the chest when coughing 2 Offering the patient an incentive spirometer every four hours 3 Instructing the patient in how to perform abdominal breathing 4 Encouraging the patient use shallow breathing during episodes of pain
Instructing the patient to splint the chest when coughing Pleuritic chest pain is triggered by chest movement and is particularly severe during coughing and deep breathing. Splinting the chest wall will reduce movement and thus ease discomfort during coughing. Use of an incentive spirometer and practicing abdominal breathing may help increase respiratory efficiency, remove secretions, and increase oxygenation, but they will not ease pleuritic pain. The patient should not be encouraged to breathe shallowly because this will increase the risk for atelectasis and decrease oxygenation.
A patient who has tuberculosis (TB) is being treated with combination drug therapy. The nurse explains that combination drug therapy is essential because of what reason? 1 It minimizes the required dosage of each of the medications. 2 It helps reduce the unpleasant siIt discourages the development of resistant strains of the TB organism.de effects of the medications. 3 It shortens amount of time that the treatment regimen will be needed. 4
It discourages the development of resistant strains of the TB organism. Recommendations for the initial treatment of tuberculosis (TB) include a four-drug regimen until drug susceptibility tests are available. After susceptibility is established, the regimen can be altered, but patients should still receive at least two drugs to prevent emergence of drug-resistance organisms. Dosage, side effects, and duration of the regimen are not reasons for combination drug therapy in a patient with TB.
The nurse recognizes that which treatment strategy is beneficial for patients with stage I colorectal tumors? 1 Resection 2 Reanastomosis 3 Chemotherapy 4 Laparoscopic surgery
Laparoscopic surgery Laparoscopic surgery is used to treat stage I colorectal tumors. Stage II colorectal tumors are treated with resection and reanastomosis. Chemotherapy is used to treat high-risk stage II, stage III, and stage IV colorectal tumors.
To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do? Select all that apply. 1 Maintain adequate fluid intake 2 Splint the chest when coughing 3 Maintain a 30-degree elevation 4 Maintain a semi-Fowler's position 5 Instruct patient to cough at end of exhalation
Maintain adequate fluid intake Splint the chest when coughing Instruct patient to cough at end of exhalation Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
A nurse is explaining the mammography procedure to a patient. Which statement best describes the procedure? 1 A method of capturing ultrasonic images of the breast 2 A method to visualize the breast's internal structure using x-rays 3 A method that uses powerful magnetic and radio waves to create images of the breast 4 A method that involves inserting a small needle into the breast tissue to obtain a tissue sample
Mammography is a method used to visualize the breast's internal structure using x-rays. An ultrasound is used to capture ultrasonic images of the breast. Magnetic resonance imaging uses powerful magnetic and radio waves to create images of the breast. A fine needle aspiration biopsy is a technique that involves inserting a small needle into the breast tissue to obtain a tissue sample.
Which auditory disorder is caused by an excessive accumulation of endolymph in the membranous labyrinth? 1 Otitis Media 2 Otosclerosis 3 Ménière's disease 4 Acoustic neuroma
Ménière's disease, also called endolymphatic hydrops, results in an excessive accumulation of endolymph in the membranous labyrinth. The volume of endolymph increases until the membranous labyrinth ruptures. Otitis media is caused by an infection of the tympanum, ossicles, and space of the middle ear. Otosclerosis is a hereditary autosomal dominant disease caused by the vascular and bony changes in the middle ear. Otoscopic examination may reveal Schwartz's sign. Acoustic neuroma is a disorder of cranial nerve VIII, on which a unilateral benign tumor grows.
The nurse assesses a patient who tests positive for human immunodeficiency virus (HIV). Which finding would the nurse identify as the highest priority for follow-up? 1 Anorexia 2 Insomnia 3 Mood swings 4 New or productive cough
New or productive cough The patient who tests positive for HIV should be informed to report a new or productive cough within 24 hours after symptoms begin. After evaluation of the cough, follow-up care for anorexia, insomnia, and mood swings is secondary.
What is the highest priority information to include in preoperative teaching for a patient scheduled for a colectomy? 1 How to care for the colostomy 2 Activity restrictions and bed rest requirements 3 Postoperative activities and pain management 4 Medications planned for use during the procedure
Postoperative activities and pain management Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of highest priority to teach the patient to cough and deep-breathe and to use pain medication. Otherwise, atelectasis and pneumonia could develop, delaying recovery from surgery and, as a result, hospital discharge. Caring for a colostomy and activity restrictions also can be discussed postoperatively. Medications for discharge should be discussed before discharge, not before surgery. To reduce the risk of adverse outcomes, the highest priority is pain control and early ambulation and activity.
A patient was exposed to human immunodeficiency virus (HIV) during unprotected intercourse. Two weeks later, the patient reports fever, swollen lymph nodes, sore throat, headache, malaise, nausea, and muscle and joint pain. Which process explains these manifestations? Select all that apply. 1 Flu 2 Seroconversion 3 Mononucleosis 4 Acute HIV infection 5 Guillain-Barré syndrome
Seroconversion Acute HIV infection In this case, the patient would have acquired HIV infection from the donor. A mononucleosis-like syndrome of fever, swollen lymph glands, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, and/or a diffuse rash often accompany seroconversion (when HIV-specific antibodies develop). These symptoms, called acute HIV infection, generally occur within 2 to 4 weeks after the initial infection and last for 1 to 3 weeks, although some symptoms may persist for several months. Many people, including health care providers, mistake acute HIV symptoms for a bad case of the flu. Some people also develop neurologic complications, such as aseptic meningitis, peripheral neuropathy, facial palsy, or Guillain-Barré syndrome. This patient has not yet developed neurologic symptoms.
The nurse is preparing education for a patient scheduled to begin radiation therapy and hormone manipulation for prostate cancer. What information is appropriate for the nurse to include? 1 Constipation is usually a problem; a high-fiber diet is recommended. 2 Sexual ability may be affected; discussion with the partner is recommended. 3 An intense daily exercise program will help prevent urinary dysfunction and fatigue. 4 Facial hair loss and a change in voice tone are expected side effects of hormone therapy.
Sexual ability may be affected; discussion with the partner is recommended. Sexual function is usually affected by radiation therapy and hormone manipulation for the treatment of prostate cancer. Therefore it is important for the nurse to suggest options to assist the patient and his partner in adapting and coping with the changes in sexual function that may become permanent. Constipation is usually not a problem with a patient undergoing radiation therapy for prostate cancer. Instead, these patients usually experience diarrhea. Radiation therapy will cause urinary dysfunction and fatigue. Intense exercise in these patients will likely worsen these symptoms. Facial hair loss and change in voice tone are not expected side effects of hormone therapy.
A patient with a rectal tumor has undergone an abdominal-perineal resection (APR). The nurse should monitor the patient for what postoperative complications? Select all that apply. 1 Hepatotoxicity 2 Sexual dysfunction 3 Delayed wound healing 4 Persistent perineal sinus tracts 5 Upper respiratory tract infection
Sexual dysfunction Delayed wound healing Persistent perineal sinus tracts APR is a colorectal cancer surgery in which both the tumor and the entire rectum are removed, and the patient has a permanent colostomy. APR involves complications such as sexual dysfunction, delayed wound healing, and persistent perineal sinus tracts. Hepatotoxicity and upper respiratory tract infections are complications associated with immunomodulators.
Which nursing intervention is most appropriate for facilitating communication with a patient who has a hearing impairment? 1 Speaking loudly and shouting if necessary 2 Asking the patient questions that can be answered with a yes or no response 3 Standing close to the patient and speaking slowly and clearly in a normal tone 4 Standing to one side of the patient when speaking and directing the voice directly into the patient's ear
Standing close to and directly in front of the patient will greatly facilitate communication. The nurse also should ensure that the patient can see the nurse's mouth to help facilitate lip-reading. Shouting at the patient with a hearing impairment distorts the voice and further hinders understanding. Asking yes-or-no questions and standing to one side and speaking directly into the patient's ear are not appropriate or effective means of communicating with the patient who has a hearing impairment.
When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? 1 Apply pressure to each eyeball for a few seconds after administration. 2 Have the patient close the eyes and move them back and forth several times. 3 Have the patient put pressure on the inner canthus of the eye after administration. 4 Have the patient try to blink out excess medication immediately after administration.
Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. Applying pressure to each eyeball, having the patient close the eyes and move them back and forth, and having the patient try to blink out excess medication will not minimize systemic effects of the medication.
The nurse is monitoring the CD4 counts from a patient with human immunodeficiency virus (HIV). When does the nurse determine that the patient will need to observe for signs of immune problems? 1 The CD4 count is 1200. 2 The CD4 count falls to 500. 3 The CD4 count falls below 200. 4 The CD4 count is greater than 500.
The CD4 count falls to 500. Immune problems start to occur when the count drops below 500 CD4 T cells. When it drops below 200 CD4 T cells, severe immune problems will develop and the patient is diagnosed with acquired immunodeficiency syndrome (AIDS). The immune system generally remains healthy if there are more than 500 CD4 T cells. A count between 800 to 1200 CD4 T cells is normal for adults who do not have any immune dysfunction.
Which nonverbal aids can the nurse adopt to effectively communicate with a patient with hearing loss? 1 Refraining from touching the client 2 Having a light source behind the speaker 3 Maintaining equal distance from both ears 4 Refraining from covering the mouth or face with hands
The nurse should not cover his or her mouth or face with the hands to communicate effectively with a patient with hearing loss. Using touch can be an effective strategy in this situation. The nurse should refrain from having light behind the speaker. The nurse should move close to the better ear while communicating with the patient with hearing loss.
The nurse has completed patient teaching for a patient who had cataract surgery on the left eye. Which statement by the patient indicates a need for further teaching? 1 "I might feel some scratchiness in my left eye." 2 "I should notice an improvement in my vision in a few days." 3 "I will call my health care provider if I notice white drainage or redness in my left eye." 4 "I will call my health care provider if I notice white drainage or redness in my left eye."
The patient will notice an improvement in vision after surgery not in a few days. Cataract surgery typically results in little to no pain, but the patient may have some scratchiness in the operative eye. Mild analgesics are usually sufficient to relieve any discomfort, but if the pain is sudden or intense, the patient should notify the health care provider because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The patient should be instructed to call the health care provider if redness or drainage occurs in the affected eye. These can be signs of infection.
The registered nurse is preparing to teach a group of nursing students about the use of verbal aids when communicating with hearing-impaired patients. Which information does the nurse include in the teaching plan? 1 Refrain from having light behind the patient. 2 Speak in a clear voice and shout at the patient. 3 Use simple sentences and rephrase sentences if required. 4 Maintain eye contact and draw the attention of the patient with hand movements.
The use of simple sentences is an example of a verbal aid that the nurse can use while communicating with a hearing-impaired patient. If required, the nurse should rephrase the sentence and use different words to help the patient understand. As a nonverbal aid, the nurse should avoid light behind the speaker, not the patient. As a verbal aid, the nurse should speak in a normal voice directly into the better ear. The nurse should not shout to make the patient understand. As a nonverbal aid, the nurse should maintain eye contact and draw attention of the patient with hand movements.
A patient has been diagnosed as BRCA1 and BRCA2 positive. The health care provider has suggested a prophylactic bilateral oophorectomy for this patient. What information should the nurse provide before this patient decides to undergo this procedure? Select all that apply. 1 This procedure will reduce the risk of acquiring breast cancer by 50%. 2 This procedure can decrease the patient's susceptibility to acquiring heart disease. 3 The patient will not be able to bear children naturally after this procedure. 4 This procedure will increase the patient's susceptibility to developing osteoporosis. 5 The patient will not have menstrual cycles after the surgery.
This procedure will reduce the risk of acquiring breast cancer by 50%. The patient will not be able to bear children naturally after this procedure. This procedure will increase the patient's susceptibility to developing osteoporosis. The patient will not have menstrual cycles after the surgery. BRCA1 and 2 genes are tumor suppressor genes that inhibit tumor development when functioning normally. Estrogen hormone has been found to be a tumor promoter. In the case of BRCA1 and BRCA2 mutations, estrogen is able to work more effectively in the development of the breast tumor; therefore, a bilateral oophorectomy is indicated in these patients. If the ovaries are removed in premenopausal women, levels of estrogen come down significantly, and thus this procedure will be helpful in reducing the risk of acquiring breast cancer by 50%. Due to the removal of the ovaries, the normal menstrual cycle does not occur, and therefore the woman is unable to conceive. Estrogen is a bone-protective and cardioprotective hormone; therefore, its loss may increase the patient's susceptibility to developing osteoporosis and heart disease.
When caring for a patient with tuberculosis, what measures should the nurse instruct the patient to take to avoid the spread of infection? Select all that apply. 1 Drink plenty of water and maintain an erect posture. 2 Throw used tissues in a paper bag and dispose with the trash. 3 Carefully wash hands after handling sputum and soiled tissues. 4 Wear a standard isolation mask when outside the patient's room. 5 Cover the nose and mouth with a tissue while coughing and sneezing. 6 Get out of bed and move freely about the hospital to keep up strength.
Throw used tissues in a paper bag and dispose with the trash. Carefully wash hands after handling sputum and soiled tissues. Wear a standard isolation mask when outside the patient's room. Cover the nose and mouth with a tissue while coughing and sneezing. In order to prevent the spread of infection, patients with tuberculosis should be encouraged to cover the nose and mouth with tissues while coughing and sneezing, to throw used tissues in a paper bag and dispose of them with the trash, to carefully wash hands after handling sputum and soiled tissues, and to wear a standard isolation mask while moving out of their room. Increasing the frequency of prolonged visits to other parts of the hospital is not advisable because it can increase the chances of infection spread; instead, such visits should be limited. Drinking plenty of water and maintaining erect posture have no effect on controlling infection.
The nurse is teaching a female patient who has undergone lymph node excision about measures to reduce lymphedema in the arm. Which action of the patient indicates the need for further teaching? 1 Pushing against the wall 2 Wearing clothing with loose fitting sleeves 3 Placing hands under the head while sleeping 4 Applying antibiotic ointment to the injury on the arm
Wearing clothing with loose fitting sleeves Lymphedema is the accumulation of lymph in soft tissues. Patients with lymphedema in the arm should wear compression sleeves to provide a mechanical massage to the arm that facilitates the passage of lymph toward the heart. Pushing against an immovable object is an example of an isometric exercise. Isometric exercises help in relieving edema by causing drainage of the fluid from the arm. Placing hands under the head while sleeping will be beneficial, because the hands are at the level of the heart, therefore preventing fluid from pooling. Injury to the affected arm should be addressed carefully and the patient is encouraged to apply an antibiotic ointment to prevent the risk of spreading infection.
A patient is discharged to home after cataract surgery. What is the most important instruction the nurse should include in the discharge teaching? 1 Restrict activity at home. 2 Wear a nighttime eye shield. 3 Do not bend, stoop, cough, or lift. 4 Wash hands before touching the eye.
When teaching postoperative home care for cataract surgery, the nurse should instruct the patient to avoid activities such as bending, stooping, coughing, or lifting because these activities can raise the intraocular pressure, which in turn can adversely affect the newly implanted lens. All other activities are permissible. Wearing a nighttime eye shield is not necessary. Washing hands before touching the eye is a general hygiene practice and not specific to postoperative care.
