Adult Health Nursing Ch. 8 and 13 Exam

Which is a sign of acute angle closure glaucoma (AACG)?

Large fixed pupil Signs of AACG would be eye pain, large fixed pupil with reddened sclera, decreased vision, nausea, and vomiting.

What is a common mistake that hinders communication when communicating with the hearing impaired?

Overaccentuating words Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice.

Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?

The lamp can cause cataracts. The proteins in the lens of the eye are vulnerable to UV light and can develop cataracts

What should a patient who has had a cataract repair avoid?

The lifting of heavy objects Postcataract patients should avoid any activity that increases the intraocular pressure, such as lifting heavy objects, stooping, and bending.

What is the first indication of macular degeneration?

The loss of central vision Macular degeneration is characterized by the slow loss of central and near vision.

What is the most interior part of the eye?

Retina The cornea is the outermost, followed by the aqueous humor, iris, lens, choroid, and the retina.

When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?

American Foundation for the Blind for a list of agencies The American Foundation for the Blind has lists of agencies to assist and educate the visually impaired patient.

During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure?

"I have to sleep in my recliner and I have this hacking cough." Left ventricular failure is often among the first of signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough.

The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask?

"Have you contacted your physician about your dental appointment?" Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction.

The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says:

"I always take off the telemetry device when I shower." Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.

Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)?

"I try to eat more green leafy vegetables, especially broccoli, spinach, and kale." Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts.

The nurse identifies the "lub" sound of the "lub/dub" of the cardiac cycle as the sound of the:

AV valves closing. The lub is the first sound of a low pitch heard when the AV valves close.

What is the process when the lens of the eye changes its curvature to focus on the retina?

Accommodation The ability of the lens to alter its curvature as it focuses on the retina is accommodation.

When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report?

Any distortion of the grid Amsler grid, a diagnostic tool for retinal disorders, requires that the patient look at the dot on the grid and report any distortion in the grid lines.

A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?

Apply a pressure dressing over the right eye socket A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours.

Which patient teaching would help to prevent venous stasis? (Select all that apply.)

Avoid crossing the legs at the knee. Elevate legs when lying in bed or sitting. Wear elastic stockings when ambulating.

What does the cataract treatment of phacoemulsification involve?

Breaking the cataract with ultrasound Phacoemulsification uses ultrasound to break up the cataract.

A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage?

CK-MB The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count, low sodium, and ESR are nonspecific.

What does diabetes retinopathy result from?

Capillaries in retina hemorrhage Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage.

What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply.)

Cultural beliefs Values Habits The nurse must consider the patient's culture, beliefs, values, and habits, as well as the special needs of the older adult.

What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply.)

Describe the surroundings. Encourage the patient to ask for verbal cues. Place patient hand on nurse's shoulder or elbow.

When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?

Detached retina The standard complaint of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes.

Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts?

Difficulty driving at night Blurring of vision and difficulty driving at night is often the first subjective symptom reported by a patient who has cataracts.

Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?

Edematous, red scaly skin on medial surface of the leg Suggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surface of the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency.

Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure.

Hearing will not return until edema subsides. Hearing improvement will not be noted until edema subsides and the packing is removed.

The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times?

In the morning Diuretics should be scheduled for morning administration to avoid causing the patient nocturia.

One of the housekeepers splashes a chemical in the eyes. What should be the first priority?

Irrigate with normal saline solution for 20 minutes. Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure.

What is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye?

Lay the patient down flat. The patient should be placed on his back to prevent loss of the aqueous humor, assessment of the eye for the location of the object and whether the pupil is regular, cover the eye to prevent movement, and obtain medical attention immediately.

How should the nurse advise a patient who has severe vertigo from labyrinthitis?

Lie immobile and hold the head in one position until the vertigo lessens. Lying immobile and holding the head in one position will lessen vertigo.

Which of the following are causes of cataracts? (Select all that apply.)

Long-term use of corticosteroids Congenital from exposure to maternal rubella Diabetes mellitus Smoking

The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patient's right leg and dorsiflexes the foot?

Pain, which would be a positive Homans' sign A positive Homans' sign for deep vein thrombosis (DVT) is a report of pain when the affected leg is flexed and the foot is dorsiflexed.

The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?

The nurse would need to determine how this patient's visual impairment affects normal functioning. "Legal blindness" refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient.

How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?

The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema. Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels.

The nurse would design teaching for a patient with Raynaud disease to include which of the following? (Select all that apply.)

Using mittens in cold weather Practicing stress-reducing techniques Complete smoking cessation Using caution when cleaning the refrigerator or freezer

The nurse recognizes the echocardiogram report that shows an ejection factor of 42% may be an indication of:

moderate heart failure. An ejection fraction (cardiac output) of 42% indicates moderate heart failure.

The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low-density lipid (LDL) of 80. The nurse's reaction is one of:

satisfaction. This is good cholesterol control. Total cholesterol of less than 200 is desirable. The higher the number of HDLs the better. A high number of LDLs puts the patient at risk for heart disease.

The nurse would assess closely for signs of right-sided heart failure which include: (Select all that apply.)

increasing abdominal girth. edema of feet and ankles. distended jugular veins. Indicators of right-sided heart failure are distended jugular veins, anorexia, abdominal distention from ascites, liver enlargement with right upper quadrant pain, and edema of feet and ankles.

The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having:

indigestion. Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI.

After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of:

infective endocarditis. Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis.

The nurse is aware that the muscle layer of the heart, which is responsible for the heart's contraction, is the:

myocardium. The myocardium is the specialized muscle layer that allows the heart to contract

The nurse clarifies that the master pacemaker of the heart is the:

sinoatrial (SA) node. The SA node is the master pacemaker of the heart.

The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between:

2 and 3. The desired INR for the monitoring of anticoagulant therapy is between 2 and 3.

The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 ft what the normal eye can see at _______ ft.

40 The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient can see at 20 ft what the person with normal vision can see at 40 ft.

The nurse caring for a patient recovering from a myocardial infarction (MI) teaches to avoid the Valsalva's maneuver during a bowel movement and use which method along with stool softeners?

Mouth breathing Mouth breathing will lessen the severity of straining and will decrease the effect of the Valsalva's maneuver on intrathoracic pressure.

When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.)

Pallor Diaphoresis Erratic behavior Cardiac rhythm changes Hypertension, vomiting, diaphoresis, hypotension, pallor, and cardiac rhythm changes are objective data seen in patients with an MI.

What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid?

Reinsert the ear mold. The whistling hearing aid is usually caused by a poor fit of the ear mold. Reinsertion of the ear mold usually stops the whistling.

The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse's most helpful response would be:

"If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital." Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably not relieve the pain.

The nurse assesses pitting edema that can be depressed approximately in and refills in 15 seconds. The nurse would document this assessment as:

+2 edema. A +2 edema can be documented if the skin can be depressed in and respond within 15 seconds.

The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for:

cessation of smoking. The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.

Following an angiogram with the insertion site of the left groin, the nurse will include in the plan of care provisions for: (Select all that apply.)

checking pedal pulses. checking color and warmth of left leg frequently sandbagging over insertion site. The pulses below the insertion site are checked to ensure patency of the vessels; the color and warmth of the left extremity is checked to ensure adequate circulation. A sandbag or other pressure device is placed over the insertion site. The patient is maintained in a supine position for several hours postprocedure.

The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse's immediate course of action would be to:

collect more information to identify his reasons for noncompliance. Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance.

The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to:

damage of the fine hair cells in the organ of Corti. Long-term exposure to loud noises can damage the fine hair cells in the organ of Corti, which causes a conductive hearing loss.

The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulant therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can:

increase the action of the Coumadin. Herbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) the action of the Coumadin.

The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK:

removes some internal layers of the cornea The LASIK procedure removes some of the internal layers of the cornea affecting the central zone of vision.

A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient's condition as:

severe heart failure. Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest.

Which may contribute to otitis media? (Select all that apply.)

Exposure to cigarette smoke Allergies Upper respiratory infections Otitis media is usually caused by an upper respiratory infection with gram-negative bacteria, such as Proteus, Klebsiella, and Pseudomonas. In addition, allergy, exposure to cigarette smoke, mycoplasma, and several viruses may be factors.

What is the difference between primary and secondary hypertension?

Secondary hypertension is caused by another disorder like renal disease. Secondary hypertension is a consistently elevated blood pressure that is caused by another disorder, such as renal disease, diabetes, or Cushing syndrome.

The nurse takes into consideration that age-related changes can affect the peripheral circulation because of:

sclerosed blood vessels. Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and narrowing of the vessel lumen.