Exam 2 Nur. 114
An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or reading books. What is the best action by the nurse? a) Request that the child be screened for myopia. b) Try to determine the cause of the child's photophobia. c) Call the parents to discuss therapy for hyperopia. d) Inform the teacher that the child has strabismus.
A
A client has been perceiving her roommate's stuffed animal as her own dog at home. The nurse determines that this misperception of reality (illusion) is improving when the client makes which statement? a) "I guess Jan needs a dog as much as I do." b) "Jan's stuffed dog looks somewhat like my dog, Trixie." c) "Jan's dog and my dog could be twins." d) "I wish Jan had not had my dog stuffed."
B
Marshall Dunbar, a 7-year-old second grader, is being seen by the pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to his right cornea and he is now at risk of developing an infection. Of the following nursing interventions, which one would be contraindicated for a client at risk for infection? a) Wash hands before examining the eyes or performing any procedure about the face. b) Change gauze eye bandages using aseptic technique. c) To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid. d) Do not use a container of ophthalmic medication for anyone other than the client.
C
The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care? a) Involve the client in usual at-home activities. b) Provide for a schedule of activities outside the home. c) Encourage the client to sleep as much as possible. d) Discourage visitors while the client is at home.
A
A nursing student is studying depression in the elderly adult. Faculty members knows the student has mastered the information when she states which of the following? a) "Sadness is most often associated with suicidal intent." b) "Treatment of depression includes counseling." c) "Depression can resolve without treatment." d) "Depression is usually not accompanied by changes in behavior."
B
An appropriate behavior modification goal for a client with anorexia nervosa would be: A. The client will eat half of every meal for a week B. The client will gain a pound per week C. The client will attend group therapy everyday D. The client will talk about food for one hour every day
B
The nurse notices that a client diagnosed with major depression and social phobia must get up and move to another area when someone sits next to her. Which action by the nurse is appropriate? a) Question the client about her avoidance of others. b) Convey awareness of the client's anxiety about being around others. c) Have nursing staff follow the client as moves away. d) Ignore the client's behavior.
B
The physician has placed a client who has suffered the loss of a child on a selective serotonin reuptake inhibitor (SSRI) for depression. The nurse is aware that the greatest risk for suicide would be during which time period? a) Once the client is discharged home with family b) Ten to fourteen days after the initial medication regime is implemented c) When the nurse sees the client visiting with other clients on the nursing unit d) On the 1-year anniversary of the child's death
B
Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? a) Astigmatism b) Emmetropia c) Hyperopia d) Myopia
D
The client with major depression states, "I am too tired to get out of bed to go to group. I just want to rest." The nurse should tell the client: a) "Perhaps you will feel better later on." b) "Attending group is an important part of your treatment plan." c) "I will let you rest for as long as you need." d) "You have been in bed long enough and need to get up."
B
The nurse should monitor for which of the following manifestations in a patient who has undergone LASIK? a) Sty formation b) Halos and glare c) Excessive tearing d) Cataract formation
B
Which statement about retinal detachment is accurate? A. Retinal detachment is a cosmetic concern but not a vision-threatening emergency B. Retinal detachment is the separation of the retina from its underlying tissue C. A posterior vitreous detachment is a commonly occurring complication of retinal detachment D. This ocular emergency only occurs when there is facial or global trauma
B
Which type of glaucoma presents an ocular emergency? a) Ocular hypertension b) Acute angle-closure glaucoma c) Normal tension glaucoma d) Chronic open-angle glaucoma
B
Which statement made by an adolescent who has just begun taking an antidepressant would indicate the need for further teaching? a) "Now that I have been taking my antidepressant for 1 week, I am going to feel better about myself." b) "Now that I have had a week of my antidepressant, it is a little easier to get up in the morning." c) "After a week of taking my antidepressant, I can sleep a little better—6 hours or so each night." d) "A week ago when I started my antidepressant, I did not care about eating. Now I want to eat a bit more."
A
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? a) Manually restrain the extremities. b) Monitor vital signs. c) Turn client to side-lying position. d) Insert an airway or bite block.
C
A client reports that before he leaves home to go anywhere, he counts the money in his wallet as many as 12 times. The nurse judges this behavior to indicate which client need? a) the need to compensate for not having had enough money to spend as a child b) the need to avoid the embarrassment of having a shortage of funds on hand c) the need to channel emotions unacceptable to him with an acceptable activity d) the need to channel excessive sexual energy into an appropriate habit
C
A client with bipolar disorder, mania, has flight of ideas and grandiosity and becomes easily agitated. To prevent harmful behaviors, which of the following should the nurse do initially? a) Encourage the client to stay in his room. b) Instruct the client to ask for medication when agitated. c) Tell the client to seek out staff when feeling agitated. d) Seclude the client at the first sign of agitation.
C
A nurse is assigned to care for a client who has a history of generalized seizures. After receiving report, she walks into the client's room and realizes that he is alone in his room, lying in bed, and having a tonic clonic seizure. Which action of the nurse is most appropriate? A. Lower side rails to prevent the client from hitting his head on them B. Check the client's heart rate and blood pressure. C. Confirm accessibility of suction equipment and check that the patient's airway is open D. Turn the client on his side and keep his arms at his sides
C
A patient has been prescribed eye drops for the treatment of glaucoma. At the yearly follow-up appointment, the patient tells the nurse that she has stopped using the medication because her vision did not improve. Which of the following is the appropriate action to be taken by the nurse? a) Refer the patient to the ED. b) Talk with the doctor about switching to a different glaucoma medication. c) Explain the therapeutic effect and expected outcome of the medication. d) Administer the medication immediately.
C
A patient presents to the ED complaining of a chemical burn to both eyes. Which of the following is the priority nursing intervention? a) Assess visual acuity. b) Assess the pH of the corneal surface. c) Irrigate both eyes. d) Obtain the Material Safety Data Sheet (MSDS).
C
A colleague has been splashed in the eye with cleaning solution. Which of the following would be the priority? a) Instilling a local anesthetic into the eye b) Finding out what the substance was c) Covering the eye with a clean sterile dressing d) Irrigating the eye immediately with tap water
D
A nurse is counseling a client with bulimia nervosa. The client states that at times she feels helpless in relation to her eating disorder. The nurse is assisting the client to set goals. The most appropriate short term goal for this client is: A. Practicing effective socialization skills B. Perceiving her body shape as acceptable C. Decreasing preoccupation with delusional thoughts D. Verbalizing the desire to increase control over stressful situations
D
A patient's vision is assessed at 20/200. The patient asks what that means. Which of the following is the most appropriate response by the nurse? a) "You see an object from 20 feet away that a person with normal vision sees from 20 feet away." b) "You see an object from 200 feet away that a person with normal vision sees from 20 feet away." c) "You see an object from 200 feet away that a person with normal vision sees from 200 feet away." d) "You see an object from 20 feet away that a person with normal vision sees from 200 feet away."
D
An admitting nurse on a rehabilitation unit notices that an elderly client with a fractured hip and severe hypothyroidism is dirty and disheveled and that his personal hygiene is very poor. As the nurse gathers admission data, she further notes that the client has few personal connections, is depressed, and doesn't seem to care about his appearance. How should the nurse improve the client's performance of self-care activities? a) Provide initial and routine hygienic care, then evaluate the client daily as treatment progresses. b) Ask the physician to refer the client to social services for a full evaluation and follow-up. c) Provide complete hygienic care and make an appointment for the client to see the hospital barber. d) Offer to take the client to the shower and help him fix his hair.
D
An elderly client has been diagnosed with bilateral cataracts. She asks the nurse to explain what this means. The nurse describes a cataract as: A. An increase in the density of the conjunctiva. B. A think film like covering over the cornea of the eye. C. A crystallinization of the pupil of the eye. D. A clouding of the lens of the eye.
D
Which of the following would a nurse least likely assess in a client experiencing anxiety? a) Muscle tension b) Sleeping difficulties c) Irritability d) Positive self-talk
D
You are working on a pediatric unit when you receive word that the unit will be admitting a toddler with febrile seizures. the nursing supervisior assigns this patient to you and tells you the patient will be coming in 15 minutes. What is the first thing you should do? A. Order a CBC, electrolytes and urinalysis B. Obtain an order for a fever reducing medication C. Prepare an ice bath to reduce fever D. Pad the side rails of the bed E. Place a vital sign monitor in the patient's room
D
The nurse is assessing a patient with open-angle glaucoma. Which of the following is true about the patient's condition? SATA A. No initial manifestation B. Abrupt onset of eye pain C. Mild increase in IOP D. Rapid increase in IOP E. Occurs unilaterally F. Occurs bilaterally G. Treated with trabeculectomy
ACFG
A hospitalized client who refuses to eat because she fears that the kitchen personnel are poisoning her food is experiencing a) Hallucinations b) Delusions c) Anorexia d) Agoraphobia
B
