Unit 2 Test NSG 1600 EAQ cognition and mobility

Detached retina

separation of the neural retina rom the pigmented retina.

Which findings would support a client's diagnosis of parkinson disease? A. Nonintentional tremors B. Frequent bouts of diarrhea C. Masklike facial expression D. Hyperextension of the nexk E. Rigidity to passive movement

A, C, E. Constipation not diarrhea is a common problem because of a weakness of muscles used in defecation. Tendency for head and neck to be drawn forward not hyperextended because loss of basal ganglia control.

Which findings would the nurse expect when completing and admission physical for a client with a diagnosis of PD A. Muscle rigidity B. Blank facial expresion C. LEaning toward the affected side D. intention tremors with movement E. Hyperetension of the affected extremity.

A,B Movement usually abolishes tremors and are known as nonintention tremors. Arms fall rigidly to the sides and do not swing in rhythm producing a shuffling gait.

Which clinical indicators would the nurse expect to find when assessing a client with Parkinson disease? A. REsting tremors B. Flattened affect C. Muscle flaccidity E. Tonic-clonic seizures F. Slow voluntary movements

A,B, E Resting nonintentinal tremors and pill-rolling movements of the thumb against the fingers is associated with descruction of the neurons. Masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flattened affect. Slow voluntary movements are associated with PD disease. Muscle rigidity not flaccidity is caused by sustained muscle contractions. Movement is jerky in quality, cogwheel rigidity.

Which client would te nurse suspect may have parkinson's disease? A-festinating gait... trunk and knee flexes when the body is rigid B. short-leg gait.... limping C- spastic gait.... uncoordinated, cross knee scissor movement D- steppage gait... increased hip and knee flexion to make a step.

A... Trunk and knee flex when the body is rigid.

A client with parkinson disease is admitted to the hospital. Which medication is prescribed to improve the physical manifestations of parkinson disease?

Carbidopa-levodopa.

The nurse is caring for a client with a fractured hip. Which is the nurse trying to prevent by placing pillows around the injured area? A. Abduction B. Adduction C. Traction D. Elevation

Abduction move limb away from median plane. Legs and hips must be alined in an abducted position to prevent internal rotation, reduce risk of dislocation, and decrease pain.

A client reports feeling nauseated immediately after cataract surgery. Which action would the nurse take? Provide some dry crackers to eat, administer the prescribed antiemetic, explain that this is expected after surgery, encourage deep breathing until nausea subsides

Administer the prescribed antiemetic.

Which instruction is important for the nurse to provide a client after cataract surgery? Remain flat for three hours, eat a soft diet for 2 days, breathe and cough deeply, avoid bending from the waist

Avoid bending from the waist. as it increases intraocular pressure. Coughing deeply increases intraocular pressure and is contraindicated

When assisting a client with Parkinson disease to ambulate, which instruction would the nurse provide the client? A. Avoid leaning forward. B. Hesitate between steps C.rest when tremors are experienced D.keep arms close to center of gravity.

Avoid leaning forward

Which clinical manifestations are found in the client diagnosed with stage 3 of parkinson disease? A. Akinesia B. Masklike face C. Postural instability ' D. Unilateral limb involvement E. Increased gait disturbances

BCE Stage 3 is characterized by postural instability and increased gait disturbances. Masklike face begins in stage two and continues to stage 3 Akinesia is manifested in stage 4 of the disease. In stage 1 of Parkinson disease, only unilateral limb involvement is seen, but it progresses to bilateral in later stages.

When obtaining informed consent for sterilization from a developmentally challenged adult client, which condition must the nurse ensure has been met? A. That a parent or guardian signs the consent B.That the client is able to explain in detail what the procedure entails C. that the client is able to comprehend the outcome of the procedure D. that a parent or guardian has encouraged the client to make teh decision

C. Client must be intellectually competent, able to comprehend the outcome of the procedure to give informed consent. Sterilization w/o adequate informed consent is a big legal issue.

Client sustains fractured ribs as a result of an accident. Which clinical indicator suggestss the client may be expereincing a complication of fractured ribs? A. Report of pain when taking deep breaths. B. client is observed splinting the fracture site. C. Diminished breath sounds on the affected side D. Bowel sounds are auscultated in the lower chest.

C. Diminished breath sounds on the affected side. Fractured ribs may penetrate the pleura and lung allowing air to fill the pleura space and collapse the lung. Pain with deep breath is expected response to tissue trauma. Splint the fracture site is an expected response to tissue trauma caused by fractured rib. Bowel sounds ausculated in lower chest suggests rupture of diaphragm not fractured ribs.

Nurse is educating the caregivers of an elderly adult with advanced parkinson disease about continuing care. Which info would the nurse provide? A. Home care is a type of continuing care in which the primary objectives are health promotion and education B. Continuing care is necessary for clients who are recovering from an acute or chronic illness or disability. C. Adult day care centers are ideal for clients whose caregivers have to be away from home during the day. D. Hospice care is a contuining care system that allows clients to live at home with comfort, independence, and dignity E. Nursing centers provide 24-hour custodial care to help residents achieve and maintain their highest level of functioning

CDE Clients recovering from chronic or acute illnesses require restorative care. Continuing care is necessary for patients who are suffering from a terminal disease, disabled, or who were never functionall independent. Primary objectives of restorative home care is health promotion and education.

Astigmatism

Curvature of the cornea that becomes unequal

A client ass the nurse what causes Parkinson disease. Which description of pathology would the nurse provide in response to the cleint? A. distintegration o the myelin sheath B. Breakdown of upper and lower neurons C. Reduced acetylcholine receptors at synapses D. degeneration of neurons of the basal ganglia

D- degeneration of neurons of the basal ganglia reducing dopamine.

According to Erikson's stages of development, which developmental conflict is a college student attempting to resolve as he struggles with indecisions about an academic major?

Identity versus role confusion

Which factors contribute to a cleints slow rate of healing? Diabetes, cataract, smoking, dermatitis, alcohol abuse

Diabetes, smoking, and alcohol abuse.

Nurse finds the client on the floor, crying for help, with signs of a hip fracture. Which action would the nurse take first? A. Administer pain medication B. Placethe affected extremity in traction C. Immobilize the affected extremity D. Notify the primary hcp on call

First immobilize the afected extremity and then contact hcp

After cataract surgery, the nurse teaches a client how to self-administer eyedrops. The nurse would reinforce the use of which technique? Placing drops on the cornea of the eye Raising the upper eyelid with gentle traction Holding the dropper tip above the conjunctival sac Squeezing the eye shut after instilling the medication

Holding the dropper tip above the conjunctival sac. Dropper tip should not touch the eye, lower lid is retracted for placement of drops. Avoid squeezing eyes shut after administration of the med as this will squeeze the medication out of the eye.

Nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions would be suspected in this older adult? Cataract, Glaucoma, hyperopia, presbyopia, macular degeneration

Hyperopia the client has farsightedness. Presbyopia is an impaired near vision that may occur with aging.

A client who previously resided in a foreign country has a chronic vitamin A deficiency which information about vitamin A would the nurse consider when assessing the client? The integral part of the retina's pigment called melanin component of the rods and cones, which control color visualization, vitamin A is the material in the cornea that prevents the formation of cataracts It is a necessary element of rhodopsin, which controls responses to light and dark environments.

It is necessary element of rhodopsin, which controls responses to light and dark environment.

An older adult fell at home and fractured the left hip. Which clinical indicator would the emergency department nurse identify as typical with a fractured left hip? A. Left hip is ecchymotic B. LEft leg is noticeably shorter than the right C. Left leg is internally rotated D. LEft hip is tender when touched

LEft leg is noticeably shorter than the right. Affected leg is externally not internally rotated with fractured hip. Pain isnt tender it is extreme and severe pain.

A client with a fractured femur is being prepared for surgery. The client develops a sudden onset of cyanosis, tachycardia, dyspnea, and restlessness. Which action would the nurse take first? A. Call the hcp B. Administer oxygen by mask C. Obtain an oxygen sat level D. Maintain the client in a semi-fowler position.

Most likely fat embolus. O2 hould be administered before hcp is called and it is helpful to assess o2 sat, but nurse needs to address oxygen needs first.

A client has closed fractures of the right femur and tibia with multiple soft tissue contusions. Which action would the nurse plan to take? A. Perform a neurovascular assessment of the extremity B. Reassure the client that these injuries are not that serious C. Gather equipment needed for the application of skeletal traction. D. Prepare the client for a surgical reduction of the injured extremity.

Perform a neurovascular assessment of the extremity. Need immediate status of the damage. Before treatment is determined the presence of nerve or vascular damage and compartment sydrome must be identified.

High-protein diet is recommended for a client recovering from a fracture. Which is the rationale for a high-protein diet for this client. A. Promotes gluconeogenesis B. produces an anti-inflammatory effect C. Promotes cell growth and bone union. D. Decreases pain med requirements.

Promotes cell growth and bone union.

Which approach would the nurse use for an older adult client with Alzheimer disease who frequenty sqitches from being pleasant and happy to being hostile and unhappy without apparent external cause?

Providing nursing care when client is receptive. BEcause clients with alzheimer disease experience lability of mood, it is best to attempt to establish a relationship and give care when they are feeling receptive.

Nurse is assessing an older male client. Which clinical findings are expected responses to the aging process? SATA Slowed neurological responses, Lowered intelligence quotient, Long-term memory impairment, Forgetfulness about recent events, reduced ability to maintain an erection

Slowed neurological responses forgetfulness about recent events reduced ability to maintain an erection

A client is diagnosed with PD and receives a prescription for levodopa therapy. Which MOA would the nurse identify for this medication? A. Blocks effects of acetylcholine B. increased production of dopamine, C. Restores the dopamine levels in the brain DPromotes the production of acetylcholine

Restores the dopamine levels in the brani, Levodopa is a precurser to dopamine.

Which monoamine oxidase inhibitor would the nurse identify as being used to treat Parkinson disease? A. Selegiline B. Phenelzine C. Isocarboxazid D- Tranlcypromine

Selegiline is a MAOI inhibitor used to treat PD. The rest are nonselective inhibitors of both type A and B used in the treatment of depression.

A client is prescribed a Monoamine oxidase inhibitor. (MAOI) Which foods would the nurse teach the client to avoid when taking this medication? Fresh fruits, Citrus fruits, Aged cheese, ripe avocados, delicatessen meats.

Should avoid foods high in tyramine. Aged and fermented foods with ripe avocados. Avoid aged cheese, ripe avocados, delicatessen meats (fermented bologna, peperroni, salami, and sausage).

Which informaton would the nurse include about future treatment and precautions when teaching a client who has glaucoma? Avoidance of cholinergics, Surgical replacement of the lens, Continuation of therapy for life, prevention of high blood pressure.

Therapy must be continued for life. Cholinergics are used to treat glaucoma, anticholinergics are contraindicated.

Macular degeneration

blurred central vision that occurs suddenly and is caused by the degeneration of the center of the retina.

Cataract

increased opacity of the lens that blocks light rays from entering the eye leading to impaired vision.

Which information would the nurse include in explaining glaucoma to a client?

increased pressure within the eyeball

Glaucoma

intraocular structural damage resulting from elevated intraocular pressure.

Which medication is the first choice of medication for the treatment of attention-deficiet/hyperactiviy disorder (ADHD)

methylphenidate

Which explanation would the nurse provide a client who asks what a cataract is? Opacity of the lens Thin film over cornea crystallization of the pupil an increase in the density of the conjunctiva.

opacity of the lens

Most common type of glaucoma

open-angle glaucoma, resulting from increased resistance to aqueous humor outflow.