Unit 5 Evolve Questions

Which technique would the nurse reinforce when teaching a client how to self-administer eyedrops after catactact surgery? A. placing the drops on the cornea of the eye B. raising the upper eyelid w/ gentle traction C. holding the dropper tip above the conjunctival sac D. squeezing the eye shut after instilling the medication

C

While assessing the eyes of a client, a HCP notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma? A. blurred central vision B. increased opacity of the lens C. elevated IOP D. changes in retinal blood vessels

C

Which info would the nurse include when teaching a client w/ Parkinson disease about carbidopa-levodopa? A. multivitamins should be taken daily B. a high protein diet should be followed C. the meds should be taken w/ meals D. alcohol consumption should be in moderation

C (to reduce nausea and vomiting)

Which complication would the nurse instruct the parents of a toddler who had a myringotomy to report upon discharge? SELECT ALL THAT APPLY A. bleeding B. headache C. increased pain D. lack of drainage E. moderate hearing loss

C, D

Which approach would the nurse take for a client w/ Alzheimer disease who is fearful and anxious about being admitted? A. exploring the reasons for the client's concerns B. reassuring the client w the presence of same staff members C. initiating the program of various planned interactions and activities D. explaining the purpose of the unit with why admission was necessary

B

Which instructions will the nurse give to a client w/ a seizure disorder who is prescribed phenytoin? A. "take the med on an empty stomach" B. "provide meticulous oral hygiene" C. "taper off the med if seizures are controlled for 3 months" D. "stop taking the med if you become pregnant"

B

Which piece of equipment will the nurse remove from the bedside of a client on seizure precautions? A. O2 B. padded tongue blade C. suction tubing and canister D. airway management equipment

B (can cause injury to teeth)

Which med would the nurse anticipate being beneficial for a client on anti-pychotic med therapy who develops parkinsonism? SELECT ALL THAT APPLY A. levodopa B. benztropine C. amantadine D. bromocriptine E. diphenhydramine

B, C, E

A client w/ a disturbed state of mind is under observation. Which manifestation indicates that the client is suffering from dementia? SELECT ALL THAT APPLY A. displaying signs of depression B. difficulty making decisions C. continuously mentioning past failures D. inability to complete purposeful work E. disturbed sleep/wake cycle

B, D

Status epilepticus develops in an adolescent w/ a seizure disorder who is taking anti-seizure meds. Which reason would the nurse identify as the most common reason for the development of status epilepticus? A. the HCP failed to account for growth spurt B. the amount prescribed is insufficient to cover activities C. the prescribed anti-seizure meds probably is not taken consistently D. the client is prescribed a med that is ineffective in preventing seizures

C

Which parent education would the nurse provide the parent caring for their infant w/ cerebral palsy? A. focus on cognitive rather than motor skills B. maintaining immobility of the limbs w/ splints C. preserve muscle tone to prevent joint contractures D. continue to offer a special formula to limit gagging

C

Which statement made by the nursing student providing care to an older adult w/ dementia indicates a need for further education? A. "i should serve food that is easy to eat" B. "i should assist the client w/ eating" C. "I should monitor weight and food intake once a month" D. "i should offer food supplements that are tasty and easy to swallow"

C (daily not monthly)

Which equipment would the nurse recommend to foster independence at home for an ambulatory client who has Parkinson disease? A. a raised toilet seat B. side rails for the bed C. crutches for ambulation D. a trapeze above the bed

A

Which explanation would the nurse provide a client who asks what a cataract is? A. an opacity of the lens B. a thin film over the cornea C. a crystallization of the pupil D. an increase in the density of the conjunctiva

A

Which info would the nurse include teaching a client w/ Parkinson disease who is having an inadequate response to levodopa therapy about selegiline? A. "the PCP should be contacted immediately if a severe headache occurs" B. "the therapeutic blood level of the med should be monitored each month" C. "the dosage of the med can be adjusted daily depending on your response that day" D. "side effects of levodopa will decrease when the selegiline and levodopa are taken concurrently"

A

Which intervention will the nurse include in a care plan for a client w/ dementia who wanders? SELECT ALL THAT APPLY A. assess and treat pain B. avoid loud music, TV, and glaring lights C. have family members monitor client activity when possible D. use chemical or physical restraint at night to keep the client in bed E. place the client at the end of the hall to allow use of the hall for wandering

A, B, C 9place client close to nurse's station)

Which intervention would be implemented by a nurse caring for a community-dwelling adult who is suffering from confusion? SELECT ALL THAT APPLY A. provide a protective environment B. assist w/ personal hygeine C. educate the client about correct body mechanics D. promote activities that reinforce reality E. teach the client's caregiver proper feeding techniques

A, B, D

Which nursing action would the nurse take when a child w/ a seizure disorder has a generalized seizure? SELECT ALL THAT APPLY A. assessing the seizure B. taking the child's VS C. turning the child on the side D. pulling the padded side rails up E. initiating O2 administration

A, C, D (impossible to take VS during a seizure, don't breathe during a seizure so O2 will do nothing)

Which clinical manifestation is expected for a client w/ moderate dementia? SELECT ALL THAT APPLY A. restlessness B. pessimism C. short attention span D. disordered reasoning E. impaired motor activities

A, C, D, E

Which finding would support a client's diagnosis of Parkinson's disease? SELECT ALL THAT APPLY A. non-intentional tremors B. frequent bouts of diarrhea C. masklike facial expression D. hyperextension of the neck E. rigidity to passive movement

A, C, E (constipation is a common problem, head and neck drawn forward)

Exposure to which element would be the reason for cataracts in a 36 year old client who is a glass worker? SELECT ALL THAT APPLY A. heat B. pesticides C. cement dust D. metal powders E. anesthetic gases

A, D

Which manifestations are associated w/ moderate dementia? SELECT ALL THAT APPLY A. sundowning B. hypervigilance C. increased inhibition D. exaggeration of premorbid traits E. inability to recognize family members

A, D (sundowning is confusion and agitation w/ an inability to sleep that gets worse in the evening)

A client w/ dementia is confused about what day it is. Which statement made by the nurse is an example of validation therapy? A. "no, try to be in your sense of reality" B. "yes, today is the day that you just mentioned" C. "you should try improving your awareness level" D. "try to recall you past memories associated w/ the day"

B

Which action would be taken by the nurse when caring for a client w/ dementia who is having trouble w/ person, place, and time? A. minimize environmental stress to reduce confusion B. let the client continue to think in his or her own way C. prompt the client to recognize the correct date and time D. ask the client to recall the past to understand the present situation

B

Which client care would be permissible for the nurse to delegate to UAP? A. playing w/ an infant who had a seizure 1 hr ago B. bathing a child w/ an IV line and a PCA pump C. taking VS from a child who received a PRN albuterol nebulizer tx 15 min ago D. feeding an infant w/ a RR of 60 who underwent cardiac surgery 1 day ago

B

Which condition would the nurse suspect when assessing an 11 month old infant sitting on the parent's lap crying and tugging at the right ear? A. child abuse B. otitis media C. hearing impairment D. URI

B

Which goal is the nurse trying to achieve by reinforcing to the client that it is important to seek tx for primary open-angle glaucoma (POAG)? A. prevent cataracts B. prevent blindness C. prevent retinal detachment D. prevent blurred distance vision

B

Which initial action would the nurse take for a nursing home resident w/ moderate Alzheimer disease who begins to engage in numerous acting-out behaviors? A. assess the client's LOC B. identify the stressors that precipitate the client's behavior C. observe the client's performance of ADLs D. monitor the side effects associated w/ the client's meds

B

Which rationale supports the nurse's instructions to a client to speak w/ a HCP b4 self-medicating w/ OTC decongestants? A. can cause nasal dryness B. can cause urinary retention C. may cause BP to decrease D. may reduce the need for glaucoma meds

B

Which statement is important for the nurse to teach a client w/ a diagnosis of Parkinson disease who is prescribed selegiline 5 mg twice a day? A. "eat food high in tyramine" B. "avoid taking this med w/ morphine" C. "take the med in the morning and evening" D. "monitor fingerstick blood glucose"

B

Which condition would the nurse suspect when an older adult has a thin white ring around the margin of her iris? A. cataract B. arcus senilis C. conjunctivitis D. macular degeneration

B (iris becomes faded and a thin white ring appears around the margin of the iris)

Which factor is unique to vascular dementia when comparing assessment findings in clients w/ vascular dementia and dementia of the Alzheimer's type? A. memory impairment B. abrupt onset of symptoms C. difficulty making decisions D. inability to use words to communicate

B (vascular dementia has an abrupt onset)

An older adult client presents w/ tremors, muscle rigidity, bradykinesia, and postural instability. In which order do the patho events involved in this condition occur? A. decreased dopamine production B. degenerative substantia nigra C. imbalance between excitatory and inhibitory neural activities D. decreased ability to refine voluntary movements

B, A, D, C

Which intervention would the nurse take to ensure the well-being of a community-dwelling older adult w/ dementia? SELECT ALL THAT APPLY A. obtain the client's med hx and educate the older adult about safe medication storage B. foster human dignity and maintain the best functioning, protecting, and safety C. teach the client to be cautious of false advertisements that promise a cure for the disease D. show the caregiver techniques to dress, feed, and toilet the older adult E. protect the client's right and provide support to maintain the physical and mental health of family members

B, D, E

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia and lives alone, w/ adult children living nearby. According to the prescribed med regimen, the client is to take meds six times throughout the day. Which nursing intervention is correct to assist the client w/ taking the meds? A. contact the client's children and ask them to hire a private-duty aide who will provide round the clock care B. develop a chart for the client. listing the times the med should be taken C. contact the PCP and discuss the possibility of simplifying the med regimen D. instruct the client and client's children to put meds in a weekly pill organizer

C

The nurse is providing pre-op teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is which type of orangism? A. viral B. fungal C. bacterial D. rickettsial

C

Which QSEN competency would the nurse comply w/ when using flowcharts to determine usefulness of bed monitoring devices for checking on dementia clients? A. safety B. informatics C. quality improvement D. pt-centered care

C

Which action would the nurse take after finding a child having a tonic-clonic seizure? A. applying restraints B. administering O2 C. protecting the child from self-injury D. inserting a plastic airway in the child's mouth

C

Which factor would be essential to consider when the nurse determines whether a unit's environment is conducive to psychological safety for a confused client w/ dementia? A. unit rules are flexible B. there is enough staff to rotate caregivers C. realistic limits and controls are set D. choices for social activities are numerous

C

Which intervention will the nurse implement when a client w/ stage 1 Alzheimer disease begins to demonstrate aphasia? A. give step by step instructions to accomplish dressing B. place a clender and clock in the client's room C. allow extra time for client to verbalize needs and thoughts D. remind client to clean and wear prescription eyeglasses

C

Which condition would the nurse suspect when an older adult is unable to see nearby objects? SELECT ALL THAT APPLY A. cataract B. glaucoma C. hyperopia D. presbyopia E. macular degeneration

C, D (hyperopia= farsightedness)

Which factor would the nurse consider when the parent of a 10 month old infant expresses frustration that this is the baby's 3rd otitis media in 3 months? A. analgesics are contraindicated B. oral antibiotics will be prescribed C. the labyrinth and cochlea are inflamed D. the eustachian tube is short and horizontal

D

Which finding is expected for a client who has a moderate level of cognitive impairment as a result of dementia? A. hypervigilance B. increased inhibition C. enhances intelligence D. accentuated premorbid traits

D

Which goal would the nurse add to the plan of care for a forgetful disordered client who has dementia? A. restrict gross motor activity to prevent injury B. prevent further deterioration in the client's condition C. maintain scheduled activities thru behavior modification D. rechannel the client's energies into more appropriate behaviors

D

Which instruction will the nurse include when teaching a client w/ Parkinson's disease who is prescribed carbidopa-levodopa? A. "take this med between meals" B. "blood levels of the med should be monitored weekly" C. "it can cause happy feelings followed by feelings of depression" D. "you may experience dizziness when moving from sitting to standing"

D

Which need would be essential in clients who have dementia? A. to relate in a consistent manner to staff B. to learn that the dtaff cannot be manipulated C. to accept controls that are concrete and fairly applied D. to have sameness and consistency in the environment

D

Which nursing intervention would be helpful in meeting the needs of an older adult w/ Alzheimer disease? A. providing nutritious foods that are high in carbs and protein B. offering opportunities for choices in the daily schedule to stimulate interest C. developing a consistent plan w/ a fixed time schedule to fulfill emotional needs D. simplifying the environment as much as possible by limiting the need for decisions

D

Which precaution would the nurse teach to a client prescribed selegiline for the tx of Parkinson disease? A. change to a standing position slowly B. take the meds between meals C. perform self-blood glucose monitoring D. withhold the next dose if nausea occurs

A (common side effect is dizziness)

Which conclusion would the home care nurse make regarding an older adult client w/ mild Alzheimer disease? A. must be supervised closely at all times B. needs a live-in home health aide to assist w/ ADLs C. should be allowed to function independently if therapeutically possible D. ought to be responsible for carrying out daily self-care activities w/o assistance

C

Which finding would lead the nurse to contact the state bureau of motor vehicles to obtain a driving evaluation for an older adult? A. cancer B. artheitis C. dementia D. depression

C

Which question is most useful when planning nursing care for a client who has a tonic-clonic seizure at work and is admitted to the ED? A. "is your job demanding or stressful most of the time?" B. "do you participate in any strenuous sports or activities on a regular basis?" C. "does anyone in your family have a hx of CNS problems?" D. "were you aware of anything different or unusual just b4 your seizure began?"

D

Which response reported by an older adult client would the nurse identify as consistent w/ the diagnosis of macular degeneration? A. "my vision is best when I dim the lights" B. "I always see halos around lights, especially at night" C. "i can't see objects in my peripheral vision" D. "i can't see objects in the center of my vision"

D

Which action would the nurse classify as a priority when caring for a client w/ tonic-clonic seizures? A. ensuring patent airway B. administering IV fluids C. monitoring LOC D. protecting the client from injury during seizures

A

Which client need would the nurse prioritize while providing care for an older adult client w/ dementia? A. safety B. self-esteem C. self-actualization D. love and belonging

A

Which of the 4 older clients whose clinical features are shown in the accompanying chart may have dementia? A. normal psychomotor behavior, normal attention, misperceptions absence B. hypokinetic psychomotor behavior, impaired attention, difficult to distinguish between reality and perceptions C. hyperkinetic psychomotor behavior, inattentive, hallucinations D. psychomotor retardation, easily distractible, illusions present

A (B and C are delirium, D is depression)

Which finding would the nurse expect when completing an admission physical for a client w/ Parkinson disease? SELECT ALL THAT APPLY A. muscle rigidity B. blank facial expression C. leaning toward the affected side D. intention tremors w/ movement E. hyperextension of the affected extremity

A, B

Which ophthalmic solution is contraindicated for clients w/ glaucoma? A. timolol B. atropine C. pilocarpine D. epinephrine

B (a mydriatic)

Which precipitating factor for depression would be common in the older adult w/o neurocognitive problems? SELECT ALL THAT APPLY A. demetia B. multiple losses C. declines in health D. a milestone birthday E. a traumatic injury

B, C

A client w/ Parkinson disease reports problems w/ bowel elimination, Which instruction should the nurse provide for the client? A. eat a banana daily B. decrease fluid intake C. take cathartics regularly D. increase residue in the diet

D

A client w/ type 2 DM is admitted to the ambulatory surgery unit for elective cataract surgery. B4 surgery the client asks the nurse, "How will my DM be managed while I am here?" Which is the best response by the nurse? A. "what did your surgeon tell you?" B. "has the anesthesiologist talked to you yet?" C. "your surgeon will write your post-op prescriptions" D. "i'm not quite certain I understand what you are asking"

D

Which type of surgery would be planned for a client w/ degeneration of corneal tissue (abnormal cornel shape)? A. keratoplasty B. cataract removal C. trabeculectomy D. LASIK

A

Which clinical indicators would the nurse expect to find when assessing a client w/ Parkinson disease? SELECT ALL THAT APPLY A. resting tremors B. flattened affect C. muscle flaccidity D. tonic-clonic seizures E. slow voluntary movements

A, B, E

Which conditions can precipitate delirium? SELECT ALL THAT APPLY A. infection B. dementia C. dehydration D. urine retention E. meds

A, C, D, E (causes of DELIRIUMS = drugs, emotional factors, low arterial O2 level, infections, retention of urine or feces, ictal or postictal state, undernutrition, metabolic conditions, subdural hematoma)W

Which term would the nurse use to describe the characteristic gait associated w/ Parkinson disease when documenting it on the client's health record? A. spastic B. steppage C. shuffling D. scissoring

C (steps are short and dragging)

Which parental statement would the nurse recognize as signs that an infant may need to be evaluated for cerebral palsy? SELECT ALL THAT APPLY A. "my baby doesn't make eye contact" B. "my baby seems to have a voracious appetite" C. "my baby was able to turn from front to back by 2 months of age" D. "I've noticed that this baby clings to me more than other children of the same age" E. "all of my other children were sitting alone by this age. this baby doesn't seem to be anywhere near sitting alone"

C, E (spasticity causes turning at an early age)

A nurse in the pediatric clinic would be most observant for signs of cerebral palsy in a 6 month old infant in which instance? A. has a 40 year old mother B. exhibiting the mono reflex C. delivered by an elective C-section birth D. born at 32 weeks gestation

D

A post-op client says to the nurse, "the person in the next room sings all night and keeps me awake." the client in the next room has dementia and is awaiting transfer to a nursing home. How can the nurse handle this situation? A. tell the next door to stop singing B. close the doors to both the clients' rooms at night C. give the complaining client the prescribed PRN sedative D. move the post-op client to a room at the end of the hall

D

A PCP diagnoses the client's condition as otitis media. Which assessment finding supports that diagnosis? A. nodules on the pinna B. redness of the eardrum C. lesions in the external canal D. excessive cerumen in the external canal

B

Which statement explains why toddles are prone to middle ear infections? A. immunological differences B. structural differences between eustachian tubes C. functional differences between eustachian tubes D. circumference differences between middle ear cavity size

B

Which s/s are characteristics of Alzheimer dementia? SELECT ALL THAT APPLY A. ambivalence B. forgetfullness C. flight of ideas D. loose associations E. expressive aphasia

B, E

Which primary objective of nursing interventions would the nurse maintain for clients w/ dementia, delirium, and other neurocognitive disorders? A. safety within the environment B. enhancement of psychological faculties C. participation in educational activities D. face-to-face contact with other clients

A

Which condition can cause a client severe pain after a cataract extraction? A. hemorrhage into the eye B. expected post-op discomfort C. isolation from sensory deprivation D. eye pressure from the protective shield

A (hemorrhage causes increased IOP)

A 2 year old toddler has hearing loss caused by recurrent otitis media. Which tx would the nurse anticipate that the HCP will recommend? A. eardrops B. myringotomy C. mastoidectomy D. steroid therapy

B

Which clinical manifestations are found in the client diagnosed w/ stage 3 of Parkinson disease? SELECT ALL THAT APPLY A. akinesia B. masklike face C. postural instability D. unilateral limb involvement E. increased gait disturbances

B, C, E (masklike face begins in stage 2 and continues into stage 3, akinesia in stage 4, unilateral limb involvement in stage 1)

Which intervention will the nurse include in a care plan for a client w/ Alzheimer disease? SELECT ALL THAT APPLY A. limit choices B. use all side rails C. toilet every 2 hours D. ask open-ended questions E. encourage participation in self-care

A, C, E

Which characteristic mental change occurs w/ delirium and differentiates it from dementia? A. daytime sleepiness B. rapid-onset confusion C. lasts over several years D. progressive deterioration

B

Which tx goal would the nurse emphasize when teaching a client w/ a diagnosis of open-angle glaucoma? A. dilate the pupil B. rest the eye muscles C. control IOP D. prevent secondary infections

C

Which complication would the nurse recognize as associated w/ frequent episodes of otitis media in infants? SELECT ALL THAT APPLY A. mastoiditis B. HF C. hearing loss D. gastroenteritis E. bacterial meningitis

A, C, E

Which physiological changes would the nurse expect to find in a client w/ a 20 year hx of type 2 DM? A. blurry, spotty, or hazy vision B. arthritic changes in the hands C. hyperactive knee and ankle jerk reflexes D. dependent pallor of the feet and lower legs

A

Which client is most appropriate to be delegated to the UAP based on the given data? A. 14 months old, severe diarrhea, acute care B. 12 years old, hand fracture, extended care C. 30 years old, bronchitis, acute care D. 50 years old, dementia, long-term care

D

How can the nurse prevent vomiting in a client who reports feeling nauseated after cataract surgery? A. administer the prescribed antiemetic medication B. provide some dry crackers for the client to eat C. explain that this is expected after surgery D. teach how to breathe deeply until the nausea subsides

A

Which type of cerebral palsy is associated w/ slow writhing movements? A. ataxic B. spastic C. dystonic D. athetoid

D (slow, wormlike, writhing movements) - ataxic = rapid, repetitive movements - spastic = hypertonicity of muscles - dystonic = combination of athetoid and spastic

The nurse is obtaining the health hx of a 7 month old infant who has had repeated episodes of otitis media. Which question is most important for the nurse to include in the interview w/ the mother? A. "please describe how you position you child during feedings" B. "tell me how often your child has had ear infections" C. "what medicine do you give your child for the ear infections?" D. "please describe you oral health practices"

A

Which action will the nurse take to support cognitive ability in clients who have Alzheimer disease? SELECT ALL THAT APPLY A. encouraging caregivers to support safe independence B. using calendars, clocks, and pictures to support memory C. providing a limited number of choices to support decision-making D. quizzing the client regularly to assess orientation to person, place, and time E. administering prescribed rivastigmine to clients w/ severe dementia

A, B, C

A 7 year old who is taking meds to prevent seizures has been seizure free for 2 years. The child's parent asks the nurse, "how much longer will my child need to take the meds?" Which answer will the nurse provide? A. "meds are continued for 3 years after the last seizure" B. "this is usually attempted after 2 years, but meds must be gradually decreased" C. "children are usually able to stop seizure meds after puberty" D. "seizure disorders are lifelong problems that require ongoing meds"

B

A client has a partial loss of peripheral vision. The client's eye exam report shows an IOP of 24. Which condition would the nurse suspect is causing these findings? A. reduced elasticity of the lens B. unevenness in the cornea C. excess production of aqueous humor D. nontransparent substances in the vitreous humor

C

Which side effects will the nurse monitor for when carbidopa-levodopa is prescribed for a client w/ Parkinson disease? SELECT ALL THAT APPLY A. vomiting B. involuntary movements C. slow HR D. changes in mood E. peripheral edema

A, B, D (tachycardia and palpations occur)

Which manifestations are seen in an older adult w/ the diagnosis of dementia? SELECT ALL THAT APPLY A. resistance to change B. inability to recognize familiar objects C. preoccupation w/ personal appearance D. inability to concentrate on new activities E. tendency to dwell on the past

A, B, D, E

Which client statement indicates that the discharge teaching after a cataract extraction and an intraocular lens implant is effective? A. "i should call the clinic if my eye begins to hurt" B. "i am so glad that I can take a shower today" C. "there will be bright flashes of light for a few days" D. "my vision should show some improvement by tomorrow"

A

Which client would the 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

Which intervention would the home health nurse who visits an older adult couple living independently implement knowing that the wife cares for the husband, who has dementia? SELECT ALL THAT APPLY A. assess the wife for caregiver burden B. arrange hospice care for the husband C. make health care decisions for the couple D. assess the husband for signs of physical abuse E. identify social support within the community

A, D, E

Which factors are unique to delirium when distinguishing between dementia and delirium? SELECT ALL THAT APPLY A. slurred speech B. lability of mood C. long-term memory loss D. visual or tactile hallucinations E. insidious deterioration of cognition F. a fluctuating LOC

A, D, F

Which adverse response would a nurse assesses for when carbidopa-lovodopa is prescribed for a client w/ Parkinson disease? SELECT ALL THAT APPLY A. nausea B. lethargy C. bradycardia D. polycythemia E. emotional changes

A, E

Which med would the nurse anticipate be prescribed to produce diuresis and inhibit formation of aqueous humor for a client w/ glaucoma? A. chlorothiazide B. acetazolamide C. methazolamide D. aclidinium bromide

B (carbonic anhydrase inhibitor)

Which action would the nurse take when shortly after admission to a mental health unit an adolescent falls to the floor and exhibits tonic-clonic movements but still continues to chew gum? A. remove the chewing gum B. document the observation C. send another client for help D. insert a tongue blade between the teeth

B (child is not having a true seizure so the gum is ok)

Which intervention would the nurse use when a client w/ dementia tries to open the door and says, "I want ti leave now." ? A. ask the client where they are going and how they plan to get there B. invite the client to attend an activity program that they enjoy C. allow the client to leave; they have the right to refuse tx D. explain that the family and doctor want them to stay for safety

B (distraction)

Which nursing intervention will be the priority when caring for a client w/ status epilepticus? A. draw blood B. establish an airway C. insert a large bore IV needle D. administer phenytoin

B (for O2 after a seizure)

Which statement would a nurse make when a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion during a seizure? SELECT ALL THAT APPLY A. these seizures are associated w/ amnesia B. these seizures increase the r/f injuries from a fall C. these seizures are most resistant to med therapy D. these seizures are preceded by perception of an offensive smell E. these seizures cause 1 sided movement of extremities in the client

B, C (atonic or akinetic seizure)

Which infection would the nurse monitor for in the toddler based on structural characteristics at this age? SELECT ALL THAT APPLY A. bronchiolitis B. ear infections C. acute sinusites D. laryngotrachebronchitis E. inflammation of the tonsils

B, C, D, E

The nurse is planning to teach the 4 point alternate crutch gait to a 9 year old child w/ cerebral palsy. How would the nurse explain this choice to the parent? A. the child has minimal step ability in the LE B. it provides for 2 points of support on the floor at all times C. it provides for equal but partial weight bearing on each limb D. the child has more power in the UE than in the LE

C (3 points of support in the floor)

The nurse is educating the caregivers of an elderly adult w/ advanced Parkinson disease about continuing care. Which info would the nurse provide? SELECT ALL THAT APPLY 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 disabilities" C. "adult day care centeres are ideal for clients whose caregivers have to be away from home during the day" D. "hospice care is a continuing care system that allows terminal clients to live at home w/ comfort, independence, and dignity" E. "nursing centers provide 24 hour custodial care to help residents achieve and maintain their highest level of functioning"

C, D, E

Which intervention would the nurse implement for a client w/ Parkinsonism who takes an anti-cholinergic med for morning stiffness and tremors in the R arm who reports some numbness in the L hand during a visit to the clinic? A. refer the client to the PCP, only if other neuro deficits are present B. ask the PCP to increase the client's dosage of the anti-cholinergic med C. stress the importance of having the client call the PCP as soon as possible D. make immediate arrangements for further medical evaluation by the client's PCP

D

Which intervention would the nurse include when developing a plan of care fir an older client w/ dementia? A. explain to the client the details of the regimen B. demonstrate interest in the client's various likes and dislikes C. be firm when dealing w/ the client's attitudes and behaviors D. provide consistency in carrying out nursing activities for the client

D

An older client describes the current situation and then offers info that goes further and further off the topic. Which pattern of communication is the client using? A. perseveration B. thought blocking C. pressured speech D. tangential thinking

D

Which clinical indicator is the nurse most liekly to identify when exploring the hx of a client w/ open-angle glaucoma? A. constant blurring B. abrupt attacks of acute pain C. sudden, complete loss of vision D. impairment of peripheral vision

D

Which description of symptoms is consistent w dementia of the Alzheimer type? A. symptom onset is fairly rapid B. symptoms will subside periodically C. symptoms are triggered by personal crisis D. symptoms reflect progressive disintegration

D

Which encouragement would a nurse give a debilitated older client w/ glaucoma who places great value on independence after discharge from the hospital? A. prevent stressful events that can increase symptoms B. conserve eyesight by not reading or watching television C. perform household chores and shopping w/o assistance D. self-administer eye meds using appropriate technique

D

Which client w/ an eye disorder would the nurse anticipate being treated w/ beta blockers? A. increased lens density, reduced visual sensory perception B. increased tear secretion, blood shot eye appearance C. degeneration of corneal tissue, severe visual impairment D. reduced outflow of aqueous humor, increased intraocular pressure

D (glaucoma)

For which clinical manifestations would the nurse assess the client diagnosed w/ Alzheimer disease? SELECT ALL THAT APPLY A. loss of recent memory B. focused attention span C. perceptual disturbances D. willingness to accept chnage E. difficulty learning something new

A, C, E

A client w/ dementia is admitted w/ a fractured hip after a fall at home. 4 hours after admission, the client's BP increases to a moderately severe HTN level and the client pulls on the bedclothes continuously. Which inference would the nurse make as the basis for an intervention? A. the client needs to go to the bathroom B. the client may have pain and be unable to verbalize it C. the client may need their bed clothes changed D. the family member feels guilty about the fall

B

Which description of the onset of symptoms would the nurse give to the client w/ a tentative diagnosis of Parkinson disease? A. suddenly B. gradually C. overnight D. irregularly

B

The nurse notes that a child is exhibiting signs of cerebral palsy. At which age are these signs usually first noticeable? A. 2 years B. 3 years C. 3 months D. 12 months

D

Which info would the nurse include in post-op teaching for a client who had cataract surgery? SELECT ALL THAT APPLY A. do not blow your nose B. remain flat for 3 hours C. eat a soft diet for 2 days D. breathe and cough deeply E. avoid bending from the waist

A, E

Which condition would the nurse suspect in an older adult who has a new onset of decreased consciousness, fatigue, and hallucinations? A. delirium B. dementia C. depression D. Alzheimer disease

A

Which etiology is the primary cause of otitis media in young children? A. sinusitis B. recurrent tonsillitis C. an inflamed mastoid process D. an obstructed eustachian tube

D

Which info is important for the nurse to include in a teaching program for a client admitted to the hospital after having a tonic-clonic seizure and being diagnosed w/ a seizure disorder? A. explain strategies a client may use to prevent physical trauma from occurring during a seizure B. teach the client to take anti-convulsant meds on an empty stomach C. teach the client that the symptoms and tx of seizure disorders are similar, regardless of the cause D. explain that sharing the knowledge of their illness w/ others is not necessary, because meds will control the seizures

A

Which information would the nurse include in explaining glaucoma to a client? A. an increase in the pressure within the eyeball B. an opacity of the crystalline lens or its capsule C. a curvature of the cornea that becomes unequal D. a separation of the neural retina from the pigmented retina

A

Which instruction about phenytoin will the nurse provide during discharge teaching to a client w/ epilepsy who us prescribed phenytoin for seizure control? A. "anti-seizure meds will probably be continued for life" B. "phenytoin prevents any further occurrence of seizures" C. "the med needs to be taken during periods of emotional stress" D. "your anti-seizure med usually can be stopped after a year's absence of seizures"

A

Which instruction would the nurse provide when assisting a client w/ Parkinson disease to ambulate? A. avoid leaning forward B. hesitate between steps C. rest when tremors are experienced D. keep arms close to the center of gravity

A

Which med is prescribed to improve the physical manifestations of Parkinson disease? A. carbidopa-levodopa B. isocarboxazid C. dopamine D. pyridoxine (vitamin B6)

A

Which monoamine oxidase inhibitor would the nurse identify as being used to treat Parkinson disease? A. selegiline B. phenelzine C. isocarboxazid D. tranylcypromine

A

Which ocular symptom would the nurse expect a client w/ a diagnosis of dry age-related macular degeneration to report? A. loss of central vision B. attacks of acute pain C. constant blurred vision D. decreased peripheral vision

A

Which response would the nurse provide to a client who develops a seizure disorder as a result of a traumatic fall and states "I have not had a seizure in 2 years. When can I stop taking my anti-seizure meds?" A. "A gradual reduction in seizure meds may be considered" B. "you will require meds for the rest of your life" C. "the meds probably will be discontinued at this visit" D. "a minimum of 10 years w/o seizures is necessary b4 discontinuation of meds in considered"

A

Which safety instruction would the nurse teach a child w/ diminished sensation in the legs because of cerebral palsy? A. test the temp of the water b4 a bath B. tighten brace straps securely b4 ambulating C. set the clock twice during the night to change position D. look down at the legs when crutch-walking to check how they are positioned

A

While in the playroom, a school aged child exhibits twitching of the R arm and leg that almost immediately progresses to a generalized tonic-clonic seizure w/ clenched jaws. Which action would the nurse take after moving the child to the floor? A. moving objects away from the child B. taking the other children to their rooms C. inserting a plastic airway into the child's mouth D. positioning a large pillow under the child's head

A

Which parent education would the nurse provide about the preferred carrying position for an infant w/ cerebral palsy prone to scissoring of the legs? A. astride one of her hips B. strapped in an infant seat C. wrapped tightly in a blanket D. under the arm in a football hold

A (muscular hypertonicity often causes scissoring of the legs and prolonged periods in such positions may worsen the infant's musculoskeletal health)

Which manifestation is an extrapyramidal side effect of chlorpromazine? SELECT ALL THAT APPLY A. drooling B. facial tics C. shuffling gait D. tongue rolling E. restless movements

A, B, C, D, E (extrapyramidal side effects are adverse effects of anti-psychotic meds)

Which condition would the nurse suspect while interacting w/ a client who reported visual changes and is frequently exposed to the sun? SELECT ALL THAT APPLY A. cataracts B. entropion C. pterygium D. pinguecula E. arcus senilis

A, C, D

Which type if eye disorder will the nurse expect to read in the EMR of a client who has increased BP, severe myopia, and high blood glucose levels? A. uveitis B. glaucoma C. corneal abrasions D. kertoconjunctivits sicca

B (glaucoma r/t DM, HTN, and severe myopia)

Which action would be taken when the nurse observes a client who is experiencing a seizure while making rounds? A. hyperextend the client's neck B. move obstacles away from the client C. restrain the client's body movements D. attempt to place an airway in the client's mouth

B

Which action would the nurse take first when caring for a client who is admitted to the ED after experiencing a seizure? A. ask the emergency provider for a prophylactic anti-convulsant B. obtain a hx of seizure type and incidence C. ask the client to remove any dentures and eyeglasses D. observe the client for increased restlessness and agitation

B

Which info would the nurse include in the teaching plan for a client diagnosed w/ epilepsy? A. the client will take anti-convulsant meds for life B. individuals taking phenytoin must floss their teeth regularly C. a diagnosis of epilepsy prevents individuals from ever obtaining a driver's licence D. loss of consciousness during a seizure requires emergency evaluation

B (gingival hyperplasia is a common side effect of phenytoin)

Which action would be considered in the collaborative plan of care for a client w/ increased lens density? SELECT ALL THAT APPLY A. performing keratoplasty B. performing phacoemulsification C. monitoring for pain and eye redness D. monitoring the client's blood glucose levels E. assessing if the client is on antiplatelet medication

B, D, E (cataracts) -glucose to determine the severity of the disease -med assessment b4 surgery -no pain or redness w/ cataracts

A RN must assess the body temp of a client w/ a hx of epilepsy. Which site for measuring temp is contraindicated in this client? A. skin B. axilla C. oral cavity D. temporal artery

C

The nurse assesses a client's eyes and notices that the pupils are unequal in size and constricted. Which condition would be found in the client's medical record? A. cataracts B. blepharitis C. anisocoria D. exophthalmos

C

Which client statement indicates that the instructions to a client w/ a seizure disorder receiving phenytoin and phenobarbital are understood? A. "i will not have any seizures w/ these meds" B. "these meds must be continues to prevent falls and injuries" C. "stopping the meds can cause continuous seizures and I may die" D. "by my staying on the meds I will prevent post-seizure confusion"

C

Which complication would the nurse assess in both clients who have Parkinson disease and clients who have myasthenia gravis? A. cogwheel gait B. impaired cognition C. difficulty swallowing D. non-intentional tremors

C

Which education would the nurse provide the parent of an infant w/ cerebral palsy to support setting care goals? A. cognitive impairments require special education B. progressive deterioration requires future institutionalization C. unknown extent of the disability requires continual adjustments D. diminished immune responses require protection from infection

C

Which info would teh nurse include about future tx and precautions when teaching a client who has glaucoma? A. avoidance of cholinergics B. surgical replacement of lens C. continuation of therapy for life D. prevention of high BP

C

Which is the most important safety measure for the nurse to institute immediately when a 2 year old child has a seizure? A. monitoring the child's VS B. padding the side rails of the toddler's crib C. placing the child in the side-lying position D. bringing suction equipment to the bedside

C

Which mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed w/ Parkinson disease? A. blocks the effects of acetylcholine B. increases the production of dopamine C. restores the dopamine levels in the brain D. promotes the production of acetylcholine

C

Which ophthalmic prescription is indicated to manage a client who has primary open-angle glaucoma? A. tetracaine B. fluorescein C. timolol maleate D. atropine sulfate

C

Which statement made by a client w/ glaucoma who is receiving a carbonic anhydrase inhibitor will require the nurse to notify the PCP? A. "I have asthma" B. "I use contact lenses" C. "I am allergic to sulfonamides" D. "i have been taking phenelzine"

C

Which symptom would the nurse expect the client who has primary open-angle glaucoma to report? A. attacks of acute eye pain B. constant blurred vision C. decreased peripheral vision D. complete loss of central eyesight

C

Which type of surgery would the nurse anticipate for a client w/ cataracts? A. keratoplasty B. trabeculoplasty C. cataract removal D. laser in situ keratomileusis (LASIK)

C

Which client would the nurse anticipate needing a referral to a support group for people w/ vision loss? A. cloudy vision B. crossing of the eyes C. obstruction of central vision D. difficulty seeing things that are far away

C (macular degeneration) -cataracts can be solved w/ a simple surgical procedure

How would the nurse describe the clonic phase of a tonic-clonic seizure? A. generalized rigidity B. loss of consciousness C. rhythmic body jerking D. tremors of UE

C (rigidity in tonic phase)

Which response would the nurse provide a parent whose infant was diagnosed w/ cerebral palsy at 6 months of age about why the infant was not diagnosed after birth? A. "the neurological lesions changed as your baby matured" B. "joint deformities don't appear until after 6 months of age" C. "the staff members didn't want to alarm you until it was necessary" D. "until there's control of voluntary movement, a diagnosis can't be confirmed"

D

Which instruction is important for the nurse to provide to the client after cataract surgery? A. remain flat for 3 hours B. eat a soft diet for 2 days C. breathe and cough deeply D. avoid bending from the waist

D (increases IOP)

Which nursing action is appropriate for a pt during the tonic-clonic stage of a seizure? A. go for additional help B. establish a patent airway C. restrain the client to prevent injury D. protect the client's head from injury

D (patent airway after the seizure)

A client asks the nurse what causes Parkinson disease. Which description of pathology would the nurse provide in response to the client? A. disintegration of 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 (reducing dopamine)

Which parent education would the nurse provide for a 4 month old infant w/ a newly diagnosed acute otitis media and fever? A. "anti-inflammatory medications are recommended for this condition" B. "typically antiviral meds are given to treat acute otitis media" C. "current practice is to wait 72 hours to see whether the condition resolves" D. "antibiotics are recommended for infants younger than 6 months w/ acute otitis media"

D (wait 72 hours for infants older than 6 months who are healthy)

A nurse provides instructions to a client who has glaucoma. Which statement made by the client after receiving the nurse's instructions indicates that the nurse needs to intervene? SELECT ALL THAT APPLY A. "i should take stool softners" B. "i can wear shirts w/ loose collars" C. "i should refrain from sneezing and coughing" D. "i can lift objects that weight more than 10 lbs" E. "i should keep my head in a dependent position"

D, E