NUR1213 Semester 2: Unit 5 Exam
Affective instability is assessed by assess which aspects ( select all that apply) A. Mood B. Cognition C. Energy D. Age
A. Mood B. Cognition C. Energy Affective instability may presents as any combination of the following: Agitation Sadness Elation Blunting Note: speech may be in a monotone during blunting and response may be usually brief
Powerpoints How is mania distinguished from hypomania? A. Hypomaina there is sundowning B. the presence of perceptual disturbances is seen in mania C. Typically hypomania patients are hospitalized D. hypomania seizures and tremors are seen
B. the presence of perceptual disturbances is seen in mania hypomania is a milder form of mania. If you're experiencing hypomania, your energy level is higher than normal, but it's not as extreme as in mania. ... If you have hypomania, you won't need to be hospitalized for it. People with bipolar II disorder may experience hypomania that alternates with depression. Presence of perceptual disturbances is seen in patient with mania
Powerpoints Which hormone is likely to be elevated in a patient with heart failure. A. ADH B. Aldosterone C. Atrial natriuretic factor D. TSH
C. Atrial natriuretic factor powerful vasodilator secreted mainly by the heart atria in response to atrial stretch Acts on the kidney to increase sodium excretion and GFR, to antagonize renal vasoconstriction, and to inhibit renin secretion promotes sodium loss at the kidneys reduces blood pressure suppresses vasopressin secretion decreases aldosterone by inhibiting the production of angiotensin
Nclex question All of the following are true about atrial natruretic peptide (ANP) are true except A. produced by cells in the heart B. promotes sodium loss at the kidneys C. reduces blood pressure D. suppresses vasopressin secretion E. increases aldosterone
E. increases aldosterone ANP decreases renin secretion, there by inhibit the production of angiotensin and aldosteron. ANP is synthesized and secreted by the cardiac muscle cells in the walls of atria in the heart
power points At a minimum when should pain be assessed?
Each new report of pain Before and after the administration of analgesic
Persistent mood disturbance is when the patient experiences ...
two weeks of melancholic feelings or four days of manic
Self adaptive *If hearing loss is detected early, proper intervention can help a child achieve normal language development. What is the latest age that hearing loss should be detected to ensure that a child achieves normal language development? Record your answer using a whole number. ______________ months
3 detect problem by 3 months and start treatment prior 6 months
The nurse has notes that the physician has a diagnosis of presbycusis on the client's chart. The nurse plans care knowing the condition is: A sensorineural hearing loss that occurs with aging A conductive hearing loss that occurs with aging. Tinnitus that occurs with aging Nystagmus that occurs with aging
A sensorineural hearing loss that occurs with aging
Powerpoints/in class discussion Which statements are true in regards to dry AMD A. Slowly progressive and painless vision loss B. More common form of AMD C. More severe form AMD D. Close vision tasks are more difficult E. More likely to lead to blindness
A, B, D Dry (nonexudative) : -more common form (90% of all cases) -Close vision tasks are more difficult - slowly progressive and painless vision loss. Wet (exudative): (Patients with wet AMD had dry AMD first.) -More severe form -Accounts for the majority of the cases of AMD-related blindness. -More rapid onset of vision loss
Nursing intervention for dehydration (select all that apply) A. Monitor I&O B. Monitor oral cavity C. Elevate HOB or Orthopneic position D. Monitor skin turgor E. Encourage PO fluids
A, B, D, E Nursing interventions for FVE: Monitor vital signs Monitor I&O Monitor lung sounds Elevate HOB or Orthopneic position Oxygen Monitor daily weights Monitor labs Administer diuretics as ordered Restrict fluid & Na intake as ordered Nursing interventions for Dehydration: Monitor vital signs Monitor I&O Monitor daily weights Monitor skin turgor Monitor oral cavity Mental functioning Encourage PO fluids Administer IVFs as ordered
Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? A. Absence of pain or pressure B. Blurred vision in the morning C. Seeing colored halos around lights D. Eye pain accompanied with nausea and vomiting
A. Absence of pain or pressure Primary open-angle glaucoma is typically symptom-free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma manifestations include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.
Self adaptive Despite receiving 2900 mL intake for 2 days, the client's urine output has progressively diminished. The nurse identifies that the urinary output is less than 40 mL/hr over the past 3 hours. What action will the nurse take? A. Assess breath sounds and obtain vital signs. B. Decrease the intravenous flow rate and increase oral fluids. C. Insert an indwelling catheter to facilitate emptying of the bladder. D. Check for dependent edema by assessing the lower extremities.
A. Assess breath sounds and obtain vital signs. The imbalance in intake and output, with a decreasing urinary output, may indicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining the vital signs are necessary when monitoring for these complications. In the presence of hypervolemia, oral and intravenous fluid intake should be decreased. There are no data to support a problem with excretion of urine; the problem is with insufficient production. The insertion of a urinary retention catheter requires a healthcare provider's prescription. Checking for dependent edema by assessing the lower extremities is an appropriate assessment after respirations and vital signs are assessed.
The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds
A. Bending over to tie shoes D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds Rationale: Any action that would increase pressure in the eye should be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects. Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.
HESI question Mrs. Hoffman's just had cataract surgery. Which approach is best to use when providing Mrs. Hoffman with discharge instructions for her postoperative care? A. Discuss ways that Mrs. Hoffman can remain independent while gradually recovering from surgery B. Insist that Mrs. Hoffman stay with her daughter for at least a day or two C. Have the HCP talk with Mrs. Hoffman's about activity restrictions D. Warn Mrs. Hoffman that if she does not limit her activity after surgery serious complications may occur
A. Discuss ways that Mrs. Hoffman can remain independent while gradually recovering from surgery Mrs. Hoffman is an independent person who wants to remain active and responsible for her own care. She will be most inclined to comply with postoperative care instructions if her independence can be maintained. Mrs. Hoffman needs to be reminded that postoperatively, her activity will be limited and she may require assistance with activities of daily living. If Mrs. Hoffman can maintain some independence while staying with her daughter, who can provide assistance, she may be more likely to stay with her daughter for a few days.
Powerpoints Which populations are at greatest risk for impaired mood and affect (select all that apply) A. Females B. Individual in the second (age 10 to 19) of life C. Individuals in the fourth decade (age 30 to 39) D. Individuals in the sixth decade (age 50 to 59)
A. Females B. Individual in the second (age 10 to 19) of life D. Individuals in the sixth decade (age 50 to 59)
The nurse is assessing an older adult client with suspected hearing loss. Which observations made by the nurse in the client indicates a decrease in hearing acuity? Select all that apply. A. Frequent usage of words such as "what" B. Postural changes while listening to the speaker C. Bending towards the other person while talking D. Mismatch in the questions asked and the responses given E. Startled expression when there is any unexpected sound in the environment
A. Frequent usage of words such as "what" B. Postural changes while listening to the speaker C. Bending towards the other person while talking D. Mismatch in the questions asked and the responses given Hearing assessment begins while observing the client listening to and answering the questions asked by the nurse. Indicators of hearing difficulty in the client frequently include asking the speaker to repeat statements or frequently saying "What?" or "Huh?" Changes in the client's posture, such as leaning forward when listening to the speaker or tilting the head to one side, can provide information about hearing acuity. The nurse should also assess whether the client's responses match the questions asked; mismatch in the client's responses may indicate a decrease in hearing acuity. Startling to an unexpected sound in the environment determines no loss in hearing acuity.
Powerpoints Pain and its effects on the cardiovascular system ( select all that apply) A. Increased post operative blood loss B. increased tumor growth C. Increased hyper-coagulation D. Increase risk for stroke and/or MI
A. Increased post operative blood loss C. Increased hyper-coagulation D. Increase risk for stroke and/or MI
Power points **which IV solution is most likely going to be given for rapid fluid replacement A. NS 0.9% B. Lactate Ringer C. NS 0.45% D. Dextran
A. NS 0.9% lactate ringer may be given for fluid replacement too ..however for RAPID fluid replacement MS 0.9% is given
powerpoints Serum Osmoality is 280. What type of IV solution due you think will be given? A. NS 0.9% B. Lactate Ringer C. NS 0.45% D. Dextran
A. NS 0.9% Serum osmolality: 275-295 Within normal levels...thus, we give solution that is most like our body...no need to disrupt well balanced electrolytes...so NS 0.9% is given since most like our body
What could be the reason for cataracts in a 36-year-old client? Select all that apply. A. Prolonged exposure to heat B. Prolonged exposure to pesticides C. Prolonged exposure to cement dust D. Prolonged exposure to metal powders E. Prolonged exposure to anesthetic gases
A. Prolonged exposure to heat D. Prolonged exposure to metal powders Glass workers are exposed to heat and metal powders for prolonged periods, which may increase their risk of developing cataracts. A prolonged exposure to pesticides may cause pesticide poisoning. Prolonged exposure to cement dust may cause bronchitis. Prolonged exposure to anesthetic gases may have reproductive effects.
Perry book Child hears some of everything going on around him or her, the sounds are distorted, severely affecting discrimination and comprehension. This is known as A. Sensorineural hearing loss B. Conductive hearing impairment C. Mixed conductive-sensorineural hearing loss D. Central auditory imperception
A. Sensorineural hearing loss
Powerpoint Signs and symptoms of dehydration (select all that apply) A. Skin tenting B. Postural hypotension C. Rapid thready pulse D. Crackles in the lungs E. Flat neck veins
A. Skin tenting B. Postural hypotension C. Rapid thready pulse E. Flat neck veins
Powerpoints Primary prevention for sensory perception A. Use of safety devices (e.g., hearing protection, eye protection) B. Vision/hearing screening C.Silver nitrate in newborn's eyes to prevent infection D. Proactive management of chronic conditions such as heart disease and diabetes
A. Use of safety devices (e.g., hearing protection, eye protection) C.Silver nitrate in newborn's eyes to prevent infection D. Proactive management of chronic conditions such as heart disease and diabetes
Powerpoints cause of cataracts include (select all that apply) A. blunt or penetrating trauma B. congenital factors C. maternal rubella D. Increased IOP E. Radiation/UV light F. corticosteroids G. optic nerve atrophy H. hyperopia I. light colored
A. blunt or penetrating trauma B. congenital factors C. maternal rubella E. Radiation/UV light F. corticosteroids Glaucoma--> Increased IOP and optic nerve atrophy
*Powerpoints/in class discussion Pt needs to instill cyclopentolate drops pre cataract surgery. What should the nurse assess/tell the patient? (select all that apply) A. patient should wear dark glasses to minimize photophobia B. Monitor for signs of systemic toxicity such as tachycardia C. produces miosis of the operative eye D. provides lubrication to the operative eye
A. patient should wear dark glasses to minimize photophobia B. Monitor for signs of systemic toxicity such as tachycardia cyclopentolate is a rapid acting mydriatic(dilate the pupil of the operative eye), effective in 25-75 minutes, accommodation returns in 6-24 hrs miosis --> contricture of pupil
Pain and its effects on the respiratory system can lead to(select all that apply) A. pneumonia B. atelectasis C. decrease the need for mechanical ventilation D. decrease insulin production
A. pneumonia B. atelectasis *increases the need for mechanical ventilation
Powerpoints cause of AMD include (select all that apply) A. retinal aging B. genetics C. maternal rubella D. long term exposure to UV lights E. cigarette use F. hyperopia G. optic nerve atrophy H. light colored eyes I. nutritional factors
A. retinal aging B. genetics D. long term exposure to UV lights E. cigarette use F. hyperopia H. light colored eyes I. nutritional factors
Powerpoints Hormones that are released in excessive amounts during pain ( select all that apply ) A.Cortisol B. Insulin C. Testosterone D. glucocorticoid E. Catecholamine
A.Cortisol D. Glucocorticoid E. Catecholamine insulin and testosterone are suppressed
A 32-year-old patient is prescribed IV gentamicin (Garamycin) after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? A.Hearing loss B.Exophthalmos C.Conjunctivitis D.Recurrent fever
A.Hearing loss Aminoglycosides such as gentamicin are drugs that are potentially ototoxic and may cause damage to the auditory nerve. When this drug is used, careful monitoring for hearing and balance problems (e.g., hearing loss, tinnitus, vertigo) is essential.
Pt has lost a lot of blood has has become hypovolemic. Which hormone is most likely going to be secreted ADH
ADH (antidiuretic ---> kidneys will reabsorb water)
Nclex question The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? A. "I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him." B. "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle." C. "Making my child wear ear plugs when she goes to a rock concert may save her hearing!" D. "I see now why when my child has a cold, he complains about everything tasting blah!"
B. "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle." Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.
HESI question Which of the following nursing actions is indicated after instilling mydriatic eye drops into Mrs. Hoffman's left eye? A. Mrs. Hoffman should be turned on her left side B. An eye patch should be placed on Mrs. Hoffman's left eye C. Lighting in the room should be increased D. Massage of Mrs. Hoffman's left eyeball
B. An eye patch should be placed on Mrs. Hoffman's left eye Mydriatic eye drops dilate the pupil and allow extra entry of light, which can be uncomfortable. An eye patch placed over the left eye would enable Mrs. Hoffman to see more clearly from her right eye and avoid any left eye discomfort from the room lights.
*Powerpoints/in class discussion How is cataracts diagnosed? A. Elevated IOP B. Decreased visual acuity C. Visual disturbances D. Direct observation of cataract by ophthalmologist or by slit lamp microscopic examination
B. Decreased visual acuity C. Visual disturbances D. Direct observation of cataract by ophthalmologist or by slit lamp microscopic examination
Powerpoints/in class discussion How can you diagnosis glacumoa (select all that apply) A. Romberg test B. Direct visualization of the angle C. Direct visualization of the cataract D. Tonometry
B. Direct visualization of the angle D. Tonometry Normal pressure ranges from 10 to 21mmHg
Self adaptive What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? A. Rapid, thready pulse B. Distended jugular veins C. Elevated hematocrit level D. Increased serum sodium level
B. Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.
Powerpoints Balance can be tested by A. Snellen chart B. Romberg test C. Heel to shin test D. Finger to nose test
B. Romberg ( ask the patient to stand unaided with their eyes closed hands at their side...slight swaying is ok but patient to stand still for the most part ) Snellen chart-->vision Heel to shin test finger to nose test for coordination
Powerpoints Pt comes in with confusion, BP is 90/60, HR 112. Labs reveal Na is 110 mEq/L. What will most likely happen next A. Nurse will get pt water and start IV of hypertonic fluids B. Start IV of hypertonic fluids C. Start IV of hypotonic fluids D. Start IV of 0.9% NS
B. Start IV of hypertonic fluids Hyponatremia < 135 mEq/L Interventions --> Hypertonic IV fluids Water restriction
power points When evaluating the cause of renal calculi the nurse will evaluate for all of the following EXCEPT A. fluid intake/dietary changes B. absent gag reflex C. medication to prevent stone formation D. recent UTI
B. absent gag reflex adequate fluid, dietary changes, medication to prevent stone formation, control infection
Med surg What type of diet may decrease the progression of advanced AMD A. Grilled chicken, bean salad, boiled egg B. dark green, leafy vegetables such as kale and spinach C. baked potato, tomato soup, oranges juice and a banana D. Cheeseburger, pound cake, and apple juice
B. dark green, leafy vegetables such as kale and spinach Nutritional factors may play a role in the progression of AMD. A dietary supplement of vitamin C, vitamin E, beta caroten, e lutein, zeaxanthin, and zinc decreases the progression of advanced AMD but has no effect on people with minimal AMD or those with no evidence of AMD. Eating lots of dark green, leafy vegetables containing lutein (e.g., kale and spinach) may help reduce the risk of AMD
When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? A."The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." B."There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." C."The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." D."There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening.
B."There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time
When the nurse arrives at 8:00 am, a client has a 1000 mL bag of D5W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 am the healthcare provider changes the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 pm to the end of the 12-hour shift at 8:00 pm, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift? Record your answer using a whole number. ___ mL
Between 8:00 am and 11:00 am, 100 mL per hour were infused. Between 11:00 am and 8:00 pm, 75 mL per hour were infused. A half cup is 4 oz, and each ounce is equivalent to 30 mL, so the juice, tea, and gelatin each provided 120 mL. Water intake was 180 mL. The 450 mL infused during the prior shift should not be included.
A prescription for an isotonic enema is written for a 2-year-old child. What is the maximal amount of fluid the nurse should administer without a specific prescription from the healthcare provider? A. 100 to 150 mL B. 155 to 250 mL C. 255 to 360 mL D. 365 to 500 mL
C. 255 to 360 mL Unless prescribed, no more than 360 mL of solution should be administered to a young child because fluid and electrolyte balance in infants and children is easily disturbed. Between 100 and 150 mL may be prescribed for a small infant. Between 155 and 250 mL may be prescribed for an older or larger infant. Between 365 and 500 mL is too much for a toddler.
Adaptive quiz A nurse is administering serum albumin intravenously to a client with ascites. In response to this therapy, what does the nurse expect to decrease? A. Confusion B. Urinary output C. Abdominal girth D. blood ammonia level
C. Abdominal girth An increased serum albumin level increases the osmotic effect and pulls fluid back into the intravascular compartment. This will increase renal flow and urine output, with a resulting decrease in abdominal girth. Urinary output therapy will increase blood volume and blood flow to the kidney, thereby increasing urinary output. Albumin therapy has no effect on blood ammonia levels. An increased, not decreased, blood ammonia level causes hepatic encephalopathy.
Power points sodium-potassium pump needed for heart functions is done by A. Osmosis B. Diffusion C. Active transport D. Passive transport
C. Active transport
During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mcmol/L). What should the nurse do first in response to this laboratory result? A. Notify the primary healthcare provider. B. Obtain current blood test results. C. Assess for decreased urine output. D. Check the intravenous (IV) infusion.
C. Assess for decreased urine output. The expected serum creatinine range is 0.7 to 1.4 mg /dL (62 to 124 mcmol/L). The nurse should obtain additional information that may indicate acute rejection; therefore, the nurse must first assess for decreased urine output and changes in vital signs. Once additional data are collected (e.g., urine output, current blood work reports) and the intravenous (IV) infusions are checked, the nurse should contact the primary healthcare provider, explain the situation, and implement further prescriptions. Eventually the nurse should ensure that proper infusion rates, along with IV medications, are being maintained after the client is first assessed for decreased urine output and for changes in vital signs. Current blood work reports should be obtained after the client is assessed for decreased urine output and changes in vital signs.
Powerpoints Pt complains of decrease in vision, abnormal color perception, glare especially at night. What does the nurse suspect A. Glaucoma B. Hyphema C. Cataract D. Macular degeneration
C. Cataract
Adaptive quiz What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. A. Tetany B Seizures C. Diarrhea D. Weakness E. Dysrhythmias
C. Diarrhea D. Weakness E. Dysrhythmias Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.
HESI question A mydriatic topical eye medication is administered into Mrs. Hoffman's left eye during surgery. Which of the following responses is expected from an anticholinergic drug that produces mydriasis? A. Decreased secretion from the affected eye B. Clouding over the pupil C. Dilation of the pupil D. Constriction of the pupil
C. Dilation of the pupil Mydriatic eye drops cause the pupil to dilate, which can aid in the extraction of the cataract.
Which second-generation antidepressant can worsen uncontrolled angle closure glaucoma? A. Trazodone B. Bupropion C. Duloxetine D. Mirtazapine
C. Duloxetine Duloxetine can worsen uncontrolled angle-closure glaucoma.
When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what should the nurse focus on? A. Recognizing that eye damage caused by glaucoma can be reversed in the early stages B. Giving anticipatory guidance about the eventual loss of central vision that will occur C. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision D. Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies
C. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision
Pt with serum osmolality of 265 would be considered? A. Normal B. Isotonic C. Hypo-osmotic D. Hyper-osmotic
C. Hypo-osmotic Normal range for serum osmolality 275-295
A client is admitted to the hospital with a potential diagnosis of excess antidiuretic hormone. Which clinical indicator should the nurse identify when assessing this client? A. Polyuria B. Dehydration C. Hyponatremia D. Hyperglycemia
C. Hyponatremia Antidiuretic hormone (ADH) causes increased resorption of water by renal tubules, which dilutes sodium levels, causing hyponatremia. ADH will decrease urine volume. ADH causes fluid retention. ADH does not alter glucose metabolism.
Powerpoints Which IV solution is typically given to replace fluid and electrolytes? A. 0.9% saline solution B. D5W C. Lactated Ringer D. Dextran
C. Lactated Ringer
Giddens/key term on study guide Pain caused by damage or disease affecting the somatosensory nervous system A. Nociceptive pain B. Somatic C. Neuropathic pain D. Visceral pain
C. Neuropathic pain Ex: diabetic neuropathy postherpetic neuralgia, phantom pain, complex regional pain syndrome, trigeminal neuralgia, and poststroke painsyndrome
Nclex question The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? A. Speak loudly, but mumble or slur the words. B. Speak loudly and clearly while facing the client. C. Speak at normal tone and pitch, slowly and clearly. D. Speak loudly and directly into the client's affected ear.
C. Speak at normal tone and pitch, slowly and clearly. Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.
Powerpoints Pt comes in with confusion, BP is 185/90, HR 112. Labs reveal Na is 155mEq/L. What will most likely happen next A. Nurse will get pt water and start IV of hypertonic fluids B. Start IV of hypertonic fluids C. Start IV of hypotonic fluids D. Start IV of 0.9% NS
C. Start IV of hypotonic fluids Hypernatremia > 145 mEq/L Assessment Findings Increased tempeture Increased heart rate Increased BP Thirst Interventions--> Hypotonic IV fluid D5W (isotonic...once in body solution becomes hypotonic)
Powerpoints Which type of urinary calculi are typically seen with UTI with proteus organisms A. Calcium B. Uric acid C. Sturvite D. Cystine
C. Sturvite
Powerpoints Ascites is an example of ________ in regards to body fluid A. First spacing B. Second spacing C. Third spacing D. Fourth spacing
C. Third spacing ****serum albumin intravenously can help decrease abdominal girth in a patient with ascites First spacing: normal distribution in ICF & ECF Second spaing: abnormal accumulation of fluid in the interstitial space. Ex/ Edema Third spacing: abnormal collection of fluid in the area between cells which is resistant to move back into ICF or plasma. Ex/ Ascites
A client has primary open-angle glaucoma. The nurse expects that the client will receive a prescription for which eyedrops? A. Tetracaine B. Cyclopentolate C. Timolol maleate D. Atropine sulfate
C. Timolol maleate Timolol maleate is a beta-adrenergic antagonist that decreases aqueous humor production and increases outflow, thereby reducing intraocular pressure. Tetracaine is a topical anesthetic; it will not reduce the increased intraocular pressure associated with glaucoma. Cyclopentolate is contraindicated because it dilates the pupil and paralyzes ciliary muscles. Atropine sulfate, a mydriatic, is contraindicated because it dilates the pupil, obstructing drainage, which increases intraocular pressure
Which of the following is a cause for mixed conductive-sensorineural hearing loss? A. Inflammation of the TM B. Damage to the vestibulocochlear C. retraction of the TM and damaged ciliary hair D. fused bony ossicles
C. retraction of the TM and damaged ciliary hair Conduction--> Inflammation of the TM and fused ossicles Sensorineural -->Damage to the vestibulocochlear
When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? A. Apply pressure to each eyeball for a few seconds after administration. B.Have the patient close the eyes and move them back and forth several times. C.Have the patient put pressure on the inner canthus of the eye after administration. D.Have the patient try to blink out excess medication immediately after administration.
C.Have the patient put pressure on the inner canthus of the eye after administration.
Nclex question The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? A. "This will help us to identify your baby's risk for ear infections the first year of life." B. "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." C. "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." D. "Imitation of sounds is the first step in language development, and it is important to identify alterations early."
D. "Imitation of sounds is the first step in language development, and it is important to identify alterations early." Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby's response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.
Nclex question An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response? A. "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell." B. "Notify your doctor immediately, because this is a concerning reaction to the medication." C. "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." D. "You should see an improvement in the next week or so. Call if this continues."
D. "You should see an improvement in the next week or so. Call if this continues." Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants
A process that allows a person to focus on near objects, such as when reading. A. Strabismus B. Anisocoria C. Myosis D. Accommodation
D. Accommodation Myosis :excessive constriction of the pupil of the eye Strabismus: condition in which the patient cannot consistently focus two eyes simultaneously on the same object ( c/o double vision) Anisocoria: Pupils are unequal in size
Adaptive quiz A client with acute kidney failure becomes confused and irritable. Upon reviewing the client's medical record, which finding does the nurse determine is the most likely cause of this behavior? A. Hyperkalemia B. Hypernatremia C. A limited fluid intake D. An increased blood urea nitrogen level
D. An increased blood urea nitrogen level An increased blood urea nitrogen level, indicating uremia, is toxic to the central nervous system and causes mental cloudiness and confusion. Hyperkalemia is associated with muscle weakness, irritability, nausea, and diarrhea. Hypernatremia is associated with firm tissue turgor, oliguria, and agitation. Dehydration can cause fatigue, dry skin and mucous membranes, and rapid pulse and respiratory rates
A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing intervention should be the nurse's priority? A. Teach about visual enhancement techniques. B.Teach nutritional strategies to improve vision. C.Assess coping strategies and support systems. D. Assess impact of vision on normal functioning.
D. Assess impact of vision on normal functioning. The most important nursing intervention is to assess the patient's ability to function with the visual impairment. The nurse will use this information to plan nursing care including assessment of the patient's coping strategies and teaching about vision enhancement techniques and nutrition.
Powerpoints Which type of urinary calculi are caused due to a recessive genetic abnormality A. Calcium B. Uric acid C. Sturvite D. Cystine
D. Cystine
A nurse is caring for a client who had a kidney transplant. Which test is most important for determining whether a client's newly transplanted kidney is working effectively? A. Increased specific gravity B. Correction of hypotension C. Elevated serum potassium D. Decreasing serum creatinine
D. Decreasing serum creatinine As the transplanted organ functions, nitrogenous wastes are eliminated, lowering the serum creatinine. As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. With end-stage kidney disease, fluid retention causes hypertension; there should be a correction of hypertension, not hypotension. After the transplant, the serum potassium should correct to within expected limits for an adult.
Powerpoints Which IV solution is known as plasma expander A. NS 0.9% B. Lactate Ringer C. NS 0.45% D. Dextran
D. Dextran stays in the vascular compartment. Is given if saline solution wasn't enough.
Powerpoints Population at greatest risk for impaired sensory A. Infants/children B. African American males C. Middle aged men with CHF D. Elderly
D. Elderly result of aging process
After the nurse provides education about hydrochlorothiazide, the client will agree to notify the healthcare provider regarding the development of which symptom? A. Insomnia B. Nasal congestion C. Increased thirst D. Generalized weakness
D. Generalized weakness Generalized weakness is a symptom of significant hypokalemia, which may be a sequela of diuretic therapy
Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? A. Constant blurring B. Abrupt attacks of acute pain C. Sudden, complete loss of vision D. Impairment of peripheral vision
D. Impairment of peripheral vision Open-angle glaucoma [1] [2] has an insidious onset, with increased intraocular pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes. Constant blurring may occur with untreated acute angle-closure glaucoma. Pain occurs in acute angle-closure, not open-angle, glaucoma. Occlusions of the central retinal artery or retinal detachment will cause a sudden loss of vision.
Powerpoints Which intervention would most likely be used in severe case of hypekalemia A. Diuretics B. Kayexalate C. IV infusion of dextrose and insulin D. hemodialysis
D. hemodialysis Diuretics --> mild hyperkalemia Kayexalate--> mild to moderate IV infusion of dextrose and insulin--> moderate
What happens to the BUN level when a patient is hypovolemia? Increases or decreases ?
Increases
Most preventable cause of hearing loss:
Noise
Adaptive quiz The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates to the nurse that the client's fluid replacement is adequate? A. Increasing hematocrit level B. Urinary output of 15 to 20 mL/hr C. Slowing of a previously rapid pulse rate D. Central venous pressure progressing from 5 to 1 mm Hg
Slowing of a previously rapid pulse rate The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. Increasing hematocrit level indicates hemoconcentration resulting from hypovolemia. Urinary output of 0.5 to 1 mL/kg/hr indicates inadequate kidney perfusion; if adequate, output should be greater than 30 mL/hr. Central venous pressure decreasing from 5 to 1 mm Hg indicates hypovolemia.
Powerpoints What happens to the urine specific gravity when a patient is hypervolemia? Increases or decreases ?
Urine specific gravity decreases (urine diluted) the higher the number the more dehydrated→ so someone who has too much water will have a VERY LOW NUMBER)
Which of the following interventions is essential when instilling Cortisporin suspension. 2 gtt right ear? Verifying the proper client and route Warming the solution to prevent dizziness Holding an emesis basin under the client's ear Positioning the client in the semi-fowlers position
Verifying the proper client and route When giving medications. a nurse follows the five R's of medication administration. The drops may be warmed to prevent pain or dizziness. but this action is not essential. An emesis basin would be used for irrigation of the ear. Put the client in the lateral position to prevent the drops from draining out for 5 minutes. not semi-fowlers position.
The nurse is performing tests to differentiate between conductive and sensorineural hearing loss. What test(s) are being performed and what results show no change in hearing?
Weber test with no lateralization and Rinne test with air conduction greater than bone conduction
Adaptive quiz A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client? A. Thirst B. Weight gain C. Urinary retention D. Urinary hesitancy
Weight gain If urine is not being produced in the presence of an average daily intake, fluid will be retained and reflected in weight gain. Oliguria is decreased urinary output. One liter of fluid weighs 2.2 pounds (1 kg). Excess fluid contributes to an increase in circulating blood volume, causing hypertension. Thirst is associated with dehydration, not hypertension and oliguria. Urinary retention is unrelated to hypertension. Urinary retention is the inability to empty the bladder. Urinary hesitancy is an involuntary delay in initiating urination and is unrelated to hypertension and oliguria.
Absence of well-formed syllables (da, na, yaya) by ____________ of age should result in immediate referral
11 months of age
Powerpoints Which IV is Isotonic (select all that apply) A. 0.9% NS B. LR C. D5W D. 0.2% NS E. 0.45% NS F. 3% NS G 5 %NS
A. 0.9% NS B. LR
Power Points Which enzyme would most likely be elevated in a patient who is hypervolemic A. ANF B. TSH C. ADH D. Aldosterone
A. ANF Atrial natriuretic factor secreted mainly by the heart atria in response to atrial stretch Acts on the kidney to increase sodium excretion and GFR, to antagonize renal vasoconstriction, and to inhibit renin secretion
Powerpoints Most common type of kidney stone? A. Calcium B. Uric acid C. Sturvite D. Cystine
A. Calcium
Untreated pain can lead to (select all that apply) A. Catabolism B. Increased RR and HR C. Shock/death D. high rates of nosocomial infections E. increased tumor growth rates F. Increased testosterone production
A. Catabolism B. Increased RR and HR C. Shock/death D. high rates of nosocomial infections E. increased tumor growth rates
Powerpoints Which IV solution is the closest to our body's plasma A. NS 0.9% B. Lactate Ringer C. NS 0.45% D. D5W
A. NS 0.9%
powerpoints Population at greatest risk for pain (select all that apply) A. neonates B. infants C. middle aged D. older adults
A. neonates D. older adults
powerpoints Signs and symptoms of affective instability A. Confabulation B Agitation C. Sadness D. Elation E. Blunting
B Agitation C. Sadness D. Elation E. Blunting
A client with glaucoma is receiving a carbonic anhydrase inhibitor. Which statement made by the client will require the nurse to notify the primary healthcare provider? A. "I have asthma." B. "I use contact lenses." C. "I am allergic to sulfonamides." D. "I have been taking phenelzine medication for three months."
C. "I am allergic to sulfonamides."
Power points Predisposing factors for uric acid stones A. African American men B. Hyperlipidemia C. Gout D. Hyperthyroidism
C. Gout
Powerpoint Pt has recurrent renal calculi. Which test is most likely to be ordered A. Renal US B. IVP C. UA D. 24 hour urine collection
D. 24 hour urine collection
Powerpoints Which IV solution is isotonic but once in our body becomes hypotonic A. NS 0.9% B. Lactate Ringer C. NS 0.45% D. D5W
D. D5W (body uses sugar as fuel and only water left) *** do not give to head injury patients or babies bc of possible cerebral edema
A client with cirrhosis of the liver and ascites has been taking chlorothiazide, a thiazide diuretic. Why did the provider add spironolactone to the client's medication regimen?
To help prevent potassium loss
Power points Who is at greatest risk for dehydration A. Infant B. male adolescent C. Middle aged diabetic male D. Elderly
A. Infant higher metabolism than adults or older people and they lack the ability to concentrate urine
A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse would be most appropriate for this patient? a. "Rinse your mouth several times a day to hydrate your taste buds." b. "Blend foods together in interesting flavor combinations." c. "Eat soft foods that are easy to chew and swallow." d. "Avoid adding spices or aromatic ingredients to food to prevent nausea."
a. "Rinse your mouth several times a day to hydrate your taste buds." Good oral hygiene is important to stimulate and hydrate taste buds. Having an unpleasant taste in the mouth discourages the patient from eating. Avoid blending foods together because this confuses the ability to discriminate flavors and taste. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable
med surg end of chapter question What should be included in the postoperative teaching of the patient who has undergone cataract surgery (select all that apply)? a. Eye discomfort is often relieved with mild analgesics. b. A decline in visual acuity is common for the first week. c. Stay on bed rest and limit activity for the first few days. d. Notify surgeon if an increase in redness or drainage occurs. e. Nighttime eye shielding and activity restrictions are essential to prevent eyestrain.
a. Eye discomfort is often relieved with mild analgesics. d. Notify surgeon if an increase in redness or drainage occurs.
Which of the following sensory changes are normal with aging? a. Impaired night vision b. Difficulty hearing low pitch c. Increase in taste discrimination d. Heightened sense of smell
a. Impaired night vision Night vision becomes impaired as physiological changes in the eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.
med surg end of chapter question Which patient behaviors would the nurse promote for healthy eyes and ears (select all that apply)? a. Wearing protective sunglasses when bicycling b. Supplemental intake of B vitamins and magnesium c. Playing amplified music at 75% of maximum volume d. Patient notifying the health care provider of tinnitus while on antibiotics e. A woman avoiding pregnancy for 4 weeks after receiving MMR immunization
a. Wearing protective sunglasses when bicycling d. Patient notifying the health care provider of tinnitus while on antibiotics
The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Disequilibrium c. Cataracts d. Peripheral neuropathy
a. Xerostomia Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns.
med surg end of chapter question The patient who has a conductive hearing loss a. hears better in a noisy environment. b. hears sound but does not understand speech. c. often speaks loudly because his or her own voice seems low. d. experiences clearer sound with a hearing aid if the loss is less than 30 dB.
a. hears better in a noisy environment.
A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit? a. The patient frequently cleans out his ears with a cotton swab. b. The patient turns one ear toward the nurse during conversation. c. The patient isolates himself from social situations. d. The patient asks the nurse to speak loudly during conversations
b. The patient turns one ear toward the nurse during conversation Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the ear would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive. Asking the nurse to speak loud alters the environment but does not adapt the patient's behavior.
med surg end of chapter question Presbyopia occurs in older individuals because a. the eyeball elongates. b. the lens becomes inflexible. c. the corneal curvature becomes irregular. d. light rays are focusing in front of the retina.
b. the lens becomes inflexible Presbyopia--> difficulty focusing on objects that are near due to reduced elasticity of the lens
Often blindness occurs during childhood. Which health preventative measure is most appropriate to prevent vision impairment? a. Screen young children early for visual impairments. b. Instruct parents to report reduced eye contact from their child immediately. c. Include rubella and syphilis screening in the preconception care plan. d. Administer prophylactic antibiotics to all newborns
c. Include rubella and syphilis screening in the preconception care plan. Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible. Prophylactic antibiotics are not appropriate for all newborns. Reporting reduced eye contact is recommended but is not a preventative measure.
Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment? a. Self-care deficit b. Risk for falls c. Social isolation d. Impaired physical mobility
c. Social isolation In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Both self-care deficit and fall risk are physiological risks for the patient. Impaired physical mobility would not apply to this patient.
Question patients using eyedrops to treat their glaucoma about a.use of corrective lenses. b.their usual sleep pattern. c.a history of heart or lung disease. d.sensitivity to opioids or depressants.
c.a history of heart or lung disease.
The nurse would utilize the Snellen chart for assessment of which patient? a. A patient who is having difficulty remembering how to perform familiar tasks b. A patient who turns the television up as loud as possible c. A patient who holds his newspaper 2 inches from his face d. A patient who frequently reports the incorrect time from the clock across the room
d. A patient who frequently reports the incorrect time from the clock across the room The Snellen chart is used to assess vision using a distance of 20 feet. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental status. Turning the television up louder indicates the need for a hearing assessment. Holding a newspaper 2 inches from the face indicates the need for assessment of near vision
The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking in a loud voice, enunciating every syllable b. Having direct conversation with the patient in his affected ear c. If the patient does not understand what the nurse is saying, repeating the phrase again d. Speaking with hands, face, and expressions
d. Speaking with hands, face, and expressions Using gestures other than just speaking helps the patient understand what you are saying and makes it a meaningful stimulus. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear.
