REVIEWER NUR 152

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client's chart and understands that normal intraocular pressure is:* 1/1 A. 2-7mmHg B.10-21mmHg C. 22-30mm Hg D. 31-35mmHg

B

A major goal of treatment for the patient with AD is to* 1/1 A. maintain patient safety. B. maintain or increase body weight. C. return to a higher level of self-care. D. enhance functional ability over time.

A

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients?* 1/1 A. Increase physical activities during the day. B. Encourage short periods of napping during the day. C. Increase fluids during the evening. D. Dispense diuretics during the afternoon hours.

A

An 82-year-old woman with chronic heart failure is cared for in the home by her only child. What problem is indicated by the caregiver's failure to provide companionship or social stimulation?* 1/1 A. neglect B. sexual abuse C. abandonment D. violation of personal rights

A

The client is diagnosed with glaucoma. Which symptom should the nurse expect the client toreport?* 1/1 A. Loss of peripheral vision B. Floating spots in the vision C. A yellow haze around everything D. A curtain coming across

A

The nurse has been caring for a patient over the past several years in an outpatient clinical. The nurse notices the patient has been much more withdrawn at visits and reports her children refuse to take her to church any more, an activity the patient has done for years and enjoys. The patient's daughter is also very demeaning to the patient at the visit. The nurse knows these can be signs of:* 1/1 A. psychological or emotional abuse B. neglect C. physical abuse D. financial abuse

A

The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response?* 1/1 A. "This must be very hard for you." B. "Don't worry, things will be fine." C."I know. It will get easier with time." D. "You need to be strong for him! Don't cry."

A

What is the recommended amount of sleep (in hours) for adults?* 1/1 A. 7-9 hours B. 4-6 hours C. 9-11 hours D. 3-4 hours

A

Which of the following is not a common risk factor in elder abuse and mistreatment.* 1/1 A. Male B. Socially isolated, depressed or lacking social support C. Live alone or another person D. Physical disability

A

Which would be an advanced stage finding in a client with wet macular degeneration?* 1/1 A. Inability to see images by looking at them directly B. Diminished perception of color C. Blurred vision when reading or doing close-up work D. Distortion of vision

A

A nurse who provides care in a clinic comes into contact with numerous older adults, many of whomhave bruises of various sizes and stages on their body. What pattern of bruising is most suggestive of possible abuse?* 1/1 A. Significant bruising on the shin region of a client's leg B. Bruising on both ears and both sides of the neck C. Bruising on the back of a client's hands D. Bruising on both of a client's elbows

B

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life?* 1/1 A. Pain B. Anxiety C. Depression D. Withdrawal

B

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action?* 1/1 A. Provide a dark room. B. Provide a well-lighted room. C. Reorient the client every 8 hours only. D. Withhold benzodiazepines and sedatives.

B

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep?* 1/1 A. Keep the room light dimmed during the day. B. Keep the room cool. C. Keep the door of the room open. D. Offer a sleep aid medication to patients on a regular basis.

B

A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer's disease. Her husband tells you that he rarely gets a good night's sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?* 1/1 A. Risk for Falls related to patient wandering behavior during the night B. Caregiver Role Strain related to continuous need for providing care C. Ineffective Therapeutic Regimen Management related to poor patient memory D. Decreased Cardiac Output related to poor myocardial contractility

B

The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test?* 1/1 A. Both eyes are assessed together, followed by the assessment of the right and then the left eye. B. The right eye is tested followed by the left eye, and then both eyes are tested. C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. D. The client is asked to stand at a distance of 40ft from the chart and to read the line that can be read 200 ft away by an individual with unimpaired vision.

B

Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimer's disease (AD)?* 1/1 A. Encourage the patient to discuss events from the past. B. Maintain a consistent daily routine for the patient's care. C. Reorient the patient to the date and time every 2 to 3 hours. D. Provide the patient with current newspapers and magazines.

B

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago?* 1/1 A. Provide complete personal hygiene care for the patient. B. Remind the patient frequently about being in the hospital. C. Reposition the patient frequently to avoid skin breakdown. D. Place suction at the bedside to decrease the risk for aspiration.

B

Which nursing action will be most effective in ensuring daily medication compliance for a patientwith mild dementia?* 1/1 A. Setting the medications up monthly in a medication box B. Having the patient's family member administer the medication C. Posting reminders to take the medications in the patient's house D. Calling the patient weekly with a reminder to take the medication

B

Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes emotional lability?* 1/1 A. Explore reasons for the client's altered mood. B. Reduce environmental stimuli to redirect the client's attention. C. Attempt humor to alter the client mood. D. Use logic to point out reality aspects

B

Which statement indicates to the nurse the client is experiencing some hearing loss?* 1/1 a. "I clean my ears every day after I take a shower". b. "I keep turning up the sound on my television". c. "My ears hurt, especially when I yawn" d. " I get dizzy when I get up from the chair".

B

When providing community health care teaching regarding the early warning signs of Alzheimer'sdisease, which signs should the nurse advise family members to report. Select all that apply.* 1/1 A. Misplacing car keys B. Losing sense of time C. Difficulty performing familiar tasks D. Problems with performing basic calculations E. Becoming lost in a usually familiar environment

B C D E

A nurse prepares a presentation regarding elder abuse and neglect. Which of the following typesof abuse should the nurse include? (Select all that apply.) (5)* 0/1 A) Alcohol (substance) B) Financial C) Mandatory D) Physical E) Psychological F) Sexual

B C D E F

The nurse monitors a terminally ill client for which physical signs of approaching death? Select allthat apply. (5)* 1/1 A. Increased appetite B. Loss of consciousness C. Loss of bowel control D. Loss of bladder control E. Decreased blood pressure F. Decreased tactile sensation

B C D E F

What type of questions might a nurse asks to assess if a client is having trouble sleeping?Select that all apply: (5)* 0/1 A. What is your name? B. What is your usual bedtime and arising time? C. Are you having difficulty getting to sleep, staying asleep or awakening? D. Do you experience any depression anxiety and irritability? E. Do you take naps? F. Rate your sleep on a scale of 1-10, with 10 your wake up rested and refreshed.

B C D E F

A 70-year-old patient has not been taking his medications for hypertension and coronary artery disease. The nurse discovers the patient's son who has control of the finances has not been purchasing the medications and the patient's bank account only has a few dollars available. This is an example of which:* 1/1 A. Self-neglect. B. Abandonment. C. Financial or material exploitation. D. Psychological abuse.

C

A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?* 1/1 A. Reorient the patient several times daily. B. Have the family bring in familiar items. C. Place the patient in a room close to the nurses' station. D. Ask the patient why the wandering episodes have occurred.

C

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient?* 1/1 A. Ineffective Coping: Multiple Stressors of New Job B. Sleep Deprivation: Difficulty Falling Asleep C. Disturbed Sleep Pattern: Altered Sleep-Wake Pattern D. Risk for Injury: Activity Intolerance/Sleep Deprivation

C

An older adult diagnosed with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority?* 0/1 A. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision B. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation C. Impaired verbal communication, related to brain impairment as evidenced by the confusion D. Insomnia, related to cognitive impairment as evidenced by wandering at night

C

An older adult who appears to be between 85 and 95 has been brought to the emergency department by emergency medical services after being found wandering in the street. The older adult is filthy, confused, and exhibits numerous bruises to the face and neck as well as signs of malnutrition and dehydration. What problem should the nurses prioritize for assessment and intervention?* 1/1 A. Hygiene B. Malnutrition C. Dehydration D. Potential elder abuse

C

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nursereviews the physician's orders, expecting which type of eye drops to be instilled?* 1/1 A. An osmotic diuretic B. A miotic agent C. A mydriatic medication D. A thiazide diuretic

C

Mrs. Jordan is an elderly client diagnosed with Alzheimer's disease. She becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:* 1/1 A. Tell the client firmly that it is time to get dressed. B. Obtain assistance to restrain the client for safety. C. Remain calm and talk quietly to the client. D. Call the doctor and request an order for sedation.

C

The nurse caring for an older adult suspects elder abuse. Which action is appropriate?* 1/1 A. Collect proof of abuse notifying the authorities. B. Confront the caretakers about the suspicion of abuse. C. Notify the authorities of the suspected elder abuse. D. Report the abuse if the older adult gives permission.

C

The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care?* 1/1 A. Self-care deficit B. Imbalanced nutrition C. Disturbed sensory perception D. Anxiety

C

The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and family?* 1/1 A. The nurse encourages the client and family to identify and discuss feelings openly. B. The nurse assists the client and family in carrying out spiritually meaningful practices. C. The nurse makes decisions for the client and family to relieve them of unnecessary demands. D. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

C

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. (3)* 1/1 A. Discourage reminiscing. B. Make the decisions for the family. C. Encourage expression of feelings, concerns, and fears. D. Explain everything that is happening to all family members. E. Touch and hold the client's or family member's hand if appropriate. F. Be honest and let the client and family know that they will not be abandoned by the nurse.

C E F

A patient is admitted to a hospital with a sleep disorder. The patient has continuous involuntarymovement of the legs during sleep. What is this condition called?* 1/1 A. Insomnia B. Sleep terror C. Obstructive sleep apnea D. Periodic limb movement disorder

D

A hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine?* 1/1 A. It reduces the secretions in the bronchi. B. It causes dilation of the bronchial smooth muscles. C. It relieves pain, which helps to reduce the dyspnea. D. It helps to reduce anxiety and oxygen consumption.

D

A student nurse was asked which of the following best describes dementia. Which of the followingbest describes the condition?* 1/1 A. Memory loss occurring as part of the natural consequence of aging B. Difficulty coping with physical and psychological change C. Severe cognitive impairment that occurs rapidly D. Loss of cognitive abilities. impairing ability to perform activities of daily living

D

It is a recurrent or chronic pattern of sleep disturbance may result from alterations of the circadiantiming system.* 1/1 A. Insomnia B. Sleep related breathing disorder C. Restless Leg syndrome D. Circadian Rhythm Disorder

D

It is a state of rest accompanied by altered consciousness and relative activity.* 0/1 A. Excitement B. Relaxation C. Sleep D. Dementia

D

The 50-year-old son of an elderly widow brings his mother to the clinic for an examination. He states that she is becoming confused and is falling in the home. When left to be examined by the nurse, the female widow appears fearful, lucid, and says that she has never fallen down in her own home. What type of situation might this elderly widow be experiencing?* 1/1 A. Psychological abuse B. Financial abuse. C. Social abuse D. Physical abuse.

D

The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses needto be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has?* 1/1 a. Corneal dystrophy b. Conjunctivitis c. Diabetic retinopathy d. Cataract

D

The clinic nurse notes that following several eye examinations, the physician has documented adiagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen's charttest expecting to note which of the following?* 1/1 A. 20/20 B. 20/40 C. 20/60 D. 20/200

D

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do- not-resuscitate (DNR) order. What is the nurse's priority action?* 1/1 A. Prepare the client for intubation and mechanical ventilation. B. Talk to the family about the client's right to change his mind. C. Administer an anti-anxiety medication to the client to ease his breathing. D. Notify the health care provider that the client is rescinding the DNR order.

D

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action?* 1/1 A. Agree to act as a witness. B. Call the health care provider (HCP). C. Ask another nurse to serve as a witness. D. Ask the client who might be available to serve as a witness.

D

The nurse is preparing to administer otic drops into an adult client's right ear. Which interventionshould the nurse implement?* 1/1 a. Grasp the earlobe and pull back and out when putting drops in the ear b. Insert the teardrops without touching the outside of the ear. c. Instruct the client to close the mouth and blow prior to instilling drops d. Pull the auricle down and back prior to instilling drops.

D

You are caring for a client at the end of life. The client tells you that they are grateful for havingconsidered and decided upon some end-of-life decisions and the appointments of those who theywish to make decisions for them when they are no longer able to do so. During this discussion withthe client and the client's wife, the client states that "my wife and I are legally married so I am so gladthat she can automatically make all healthcare decisions on my behalf without a legal durable powerof attorney when I am no longer able to do so myself" and the wife responds to this statement with,"that is not completely true. I can only make decisions for you and on your behalf when thesedecisions are not already documented on your advance directive." How should you, as the nurse,respond to and address this conversation between the husband and wife and the end of life?* 0/1 A. You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions. B. You should be aware of the fact that the wife of the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need. C. You should be aware of the fact that the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need. D. You should reinforce the wife's belief that legally married spouses automatically serve for the other spouse's durable power of attorney for health care decisions and that other than the spouse cannot be legally appointed while people are married.

D