CH 60-70

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? A) Apply warm or cool cloths to the forehead or back of the neck B) Maintain hydration by drinking eight glasses of fluid a day C) Perform the Heimlich maneuver D) Use pressure-relieving pads or a similar type of mattress

A) Apply warm or cool cloths to the forehead or back of the neck Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? A) Apply warm or cool cloths to the forehead or back of the neck. B) Maintain hydration by drinking eight glasses of fluid a day. C) Perform the Heimlich maneuver. D) Use pressure-relieving pads or a similar type of mattress.

A) Apply warm or cool cloths to the forehead or back of the neck Warmth promotes vasodilation; cool stimuli reduce blood flow.

In a client with burns on the legs, which nursing intervention helps prevent contractures? A) Applying knee splint B) Elevating the foot of the bed C) Hyperextending the client's palms D) Performing shoulder range-of-motion exercises

A) Applying knee splint Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury? A) Frontal lobe B) Parietal lobe C) Occipital lobe D) Temporal lobe

A) Frontal lobe The frontal lobe, the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions (Hickey, 2009).

Which term refers most precisely to a localized skin infection of a single hair follicle? A) Furuncle B) Carbuncle C) Cheilitis D) Comedone

A) Furuncle Furuncles occur anywhere on the body but are most prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, or the buttocks. A carbuncle is a localized skin infection involving several hair follicles. Cheilitis refers to dry cracking at the corners of the mouth. Comedones are the primary lesions of acne, caused by sebum blockage in the hair follicle.

Development of malignant melanoma is associated with which risk factor? A) History of severe sunburn B) African American heritage C) Skin that tans easily D) Residence in the Northeast

A) History of severe sunburn Ultraviolet rays are strongly suspected as the etiology of malignant melanoma. Fair-skinned, blue-eyed, light-haired people of Celtic or Scandinavian origin are at higher risk for developing malignant melanoma. People who burn and do not tan are at risk for developing malignant melanoma. Elderly individuals who retire to the southwestern United States seem to have a higher incidence of developing malignant melanoma.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? A) Lung auscultation and measurement of vital capacity and tidal volume B) Evaluation for signs and symptoms of increased intracranial pressure (ICP) C) Evaluation of pain and discomfort D) Evaluation of nutritional status and metabolic state

A) Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

The red reflex occurs when a normal orange glow is observed as light is applied to which of the following? A) Pupil B) Iris C) Optic disk D) Eye lid

A) Pupil A normal orange glow is observed as light is applied to the pupil, called a red reflex. Absence of red reflex may indicate lens opacity, which is consistent with a cataract, detached retina, or retinoblastoma in children.

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear? A) Scleral buckle B) Pars plana vitrectomy C) Pneumatic retinopexy D) Phacoemulsification

A) Scleral buckle The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.

Sudoriferous glands secrete which type of substance? A) Sweat B) Oil C) Hormones D) Cerumen

A) Sweat Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment? A) The inability to tell how a mouse and a cat are alike B) The inability to maintain steady balance for the Romberg test C) Absence of movement below the waist D) Intentional tremors

A) The inability to tell how a mouse and a cat are alike The client with damage to the frontal cortex will display a deficit in intellectual functioning. Questions designed to assess this capacity might include the ability to recognize similarities: for example, how are a mouse and dog or pen and pencil alike? The Romberg test assesses balance, which has to do with the cerebellar and basal ganglia influence on the motor system. Absence of movement below the waist suggests a deficit with the spinal cord. Intentional tremors have to do with deficits of the motor system.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in A) thought content. B) motor ability. C) intellectual function. D) emotional status.

A) Thought content Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? A) Weakness on one side of the body and difficulty with speech B) Severe headache and early change in level of consciousness C) Foot drop and external hip rotation D) Vomiting and seizures

A) Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly

Which of the following is the main refracting surface of the eye? A) Cornea B) Iris C) Pupil D) Conjunctiva

A) cornea The cornea is a transparent, avascular, domelike structure that covers the iris, pupil, and anterior chamber. It is the most anterior portion of the eyeball and is the main refracting surface of the eye. The iris is the colored part of the eye. The pupil is a space that dilates and constricts in response to light. Normal pupils are round and constrict symmetrically when a bright light shines on them. The conjunctiva provides a barrier to the external environment and nourishes the eye.

A client has received a diagnosis of hyperopia and is wondering if there is a physical condition that has caused these vision changes. In explaining hyperopia, what does the nurse indicate is the cause of this client's vision changes? A) eyeballs that are shorter than normal B) irregularly shaped corneas C) unequal curvatures in the cornea D) eyeballs that are longer than normal

A) eyeballs that are shorter than normal Hyperopia results when the eyeball is shorter than normal, causing the light rays to focus at a theoretical point behind the retina.

A client with a history of diabetes mellitus has recently developed furunculosis. What is causing the client's condition? A) infection B) diet C) hygiene D) unknown

A) infection Furuncles and carbuncles are caused by skin infections with organisms that usually exist harmlessly on the skin surface.

Which category of drugs is contraindicated in clients with glaucoma? A) mydriatics B) NSAIDs C) beta-blockers D) prostaglandins

A) mydriatics Dilation of the pupil can further obstruct drainage of aqueous fluid, raise IOP, and damage whatever vision remains. Atropine is contraindicated in clients with glaucoma

After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms? A) retinal detachment B) angle-closure glaucoma C) eye trauma D) chalazion

A) retinal detachment A detached retina is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? A) "You must lie flat for 24 hours after surgery." B) "You must avoid coughing, sneezing, and blowing your nose." C) "You must restrict your fluid intake." D) "You must report ringing in your ears immediately."

B) "You must avoid coughing, sneezing, and blowing your nose." After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing? A) Anemia B) Carbon monoxide poisoning C) Polycythemia D) Shock

B) Carbon monoxide poisoning

Which is the earliest sign of increasing intracranial pressure? A) Vomiting B) Change in level of consciousness C) Headache D) Posturing

B) Change in LOC The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

Which is a correct rationale for encouraging a client with otitis externa to eat soft foods? A) Chewy foods, such as red meat, may react with prescribed analgesics and antibiotics. B) Chewing may cause discomfort. C) Chewing may lead to further complications, such as otitis media. D) Chewing may cause excessive drainage.

B) Chewing may cause discomfort. The nurse encourages a client with otitis externa to eat soft foods or consume nourishing liquids because chewing may cause discomfort. Chewing will not react with the prescribed medications or cause complications such as otitis media and excessive drainage.

Which term describes the transfer of heat from the body to a cooler object in contact with it? A) Radiation B) Conduction C) Lichenification D) Evaporation

B) Conduction Conduction is one of the three major physical processes are involved in loss of heat from the body to the environment. Radiation is the transfer of heat to another object of lower temperature situated at a distance. Lichenification is the leather thickening of the skin. Convection consists of movement of warm air molecules away from the body.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. A) Cranial nerve I B) Cranial nerve II C) Cranial nerve III D) Cranial nerve IV

B) Cranial nerve II

A patient is exhibiting bradykinesia, rigidity, and tremors related to Parkinson's disease. The nurse understands that these symptoms are directly related to what decreased neurotransmitter level? A) Acetylcholine B) Dopamine C) Serotonin D) Phenylalanine

B) Dopamine Parkinson's disease is associated with decreased levels of dopamine resulting from degeneration of dopamine storage cells in the substantia nigra in the basal ganglia region of the brain.

A nurse is caring for a client experiencing an exacerbation of plaque psoriasis. The nurse assesses the area and documents a proliferation of which cell type? A) Dermal B) Epidermal C) Endothelial D) Epithelia

B) Epidermal The nurse is correct to document that the proliferation of skin cells occurs in the first layer of skin cells, the epidermis. In the epidermal layer, there is rapid turnover of the cells. The dermis is under the epidermis. Endothelial is the layer on the inside such as the interior of the blood vessel. Epithelia are on the outside or coating of walls.

A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal? A) Umbo in the center of the tympanic membrane B) External auditory canal erythema C) Tympanic membrane pearly gray D) Manubrium superior to the umbo

B) External auditory canal erythema An erythematous external auditory canal would be considered an abnormal finding. The tympanic membrane is normally pearly gray and translucent. The umbo, which is located in the center of the eardrum, extends from the superior manubrium.

When describing the layers of the skin to a group of nursing students, which of the following would the nursing instructor include as being a component of the dermis? A) Melanocytes B) Fibroblasts C) Keratin D) Adipose tissue

B) Fibroblasts The dermis consists of two layers: the papillary dermis, which is composed primarily of fibroblasts, and the reticular layer, which produces collagen and elastic bundles. The dermis contains melanocytes and keratin. Adipose tissue is found in the subcutaneous tissue.

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? A) Sebum deficiency B) Fluid retention C) Dehydration D) Protein deficiency

B) Fluid retention Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? A) Hemoconcentration B) Hemodilution C) Metabolic acidosis D) Lack of erythropoietin factor

B) Hemodilution Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level.

The client is having a Weber test. During a Weber test, where should the tuning fork be placed? A) On the mastoid process behind the ear B) In the midline of the client's skull or in the center of the forehead C) Near the external meatus of each ear D) Under the bridge of the nose

B) In the midline of the client's skull or in the center of the forehead The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose

To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treat inflammatory conditions of the eyes? A) Miotics B) NSAIDs C) Mydriatics D) Cycloplegics

B) NSAIDS

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? A) Mechanical B) Natural C) Enzymatic D) Surgical

B) Natural Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for: A) Tonometry. B) Ophthalmoscopy. C) Gonioscopy. D) Perimetry.

B) Ophthalmoscopy. Four major types of examinations are used in glaucoma evaluation, diagnosis, and management: tonometry to measure the IOP, ophthalmoscopy to inspect the optic nerve, gonioscopy to examine the filtration angle of the anterior chamber, and perimetry to assess the visual fields.

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate? A) Cataract B) Presbyopia C) Myopia D) Macular degeneration

B) Presbyopia Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? A) Vitiligo B) Psoriasis C) Melanoma D) Petechia

B) Psoriasis Scales are flakes of desquamated, dead epithelium that may adhere to the skin surface. They may be of various colors (silvery, white) and textures (thick, fine). Examples include dandruff, psoriasis, dry skin, pityriasis, and rosea.

Treatment of melanoma includes which of the following? A) Cryosurgery B) Radical excision C) Radiation therapy D) Laser surgery

B) Radical excision The treatment of a melanoma involves radical excision of the tumor and adjacent tissues, followed by chemotherapy. Laser surgery and cryosurgery is not used in the treatment of melanoma. Radiation is used in some types of cancer.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: A) Measure hourly urinary output. B) Replace lost fluids and electrolytes. C) Prevent renal shutdown. D) Monitor cardiac status.

B) Replace lost fluids and electrolytes. After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.

A frontal lobe brain abscess produces which manifestation? A) Localized headache B) Seizures C) Ataxia D) Nystagmus

B) Seizures A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache. A temporal lobe brain abscess is manifested by localized headache. A cerebellar abscess is manifested by ataxia and nystagmus.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A) To prevent collapse and further injuries B) To keep fire and smoke from airway C) To extinguish flames more quickly D) To promote blood flow to the brain and vital organs

B) To keep fire and smoke from airway The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. Stop, drop, and roll method is a quick efficient means to distinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? A) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B) Urine output of 20 ml/hour C) White pulmonary secretions D) Rectal temperature of 100.6° F (38° C)

B) Urine output of 20 ml/hour A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

A client is color blind. The nurse understands that this client has a problem with: A) rods. B) cones. C) lens. D) aqueous humor.

B) cones. Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? A) "Are the victims suffering from thermal burns?" B) "How many victims are anticipated for transport?" C) "Are the burns associated with chemicals used in the plant?" D) "Are any of the victims expected to have electrical burns?

C) "Are the burns associated with chemicals used in the plant?" If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as: A) Chronic open-angle. B) Normal tension. C) Acute angle- closure D) Chronic angle-closure.

C) Acute angle- closure

A nurse is teaching a client about vitamins. What vitamin would the nurse recommend the client attain by exposing the skin to ultraviolet light on a daily basis? A) Retinol B) Ascorbic acid C) Cholecalciferol D) Tocopherol

C) Cholecalciferol Skin exposed to ultraviolet light can convert substances necessary for synthesizing cholecalciferol, or vitamin D. This vitamin is essential for preventing osteoporosis and rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus. Retinol, vitamin A, supports vision and the immune system. Ascorbic acid, vitamin C, supports the immune system and wound healing. Tocopherol, vitamin E, supports the immune system.

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? A) Jacksonian B) Absence C) Generalized D) Sensory

C) Generalized A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.

A 37-year-old mother of three has just been diagnosed with a grade I meningioma. As part of patient education, the nurse tells the patient that: A) The tumor is malignant and aggressive B) The tumor will cause pressure on the eighth cranial nerve. C) Growth is slow and symptoms are caused by compression rather than tissue invasion. D) Surgery, which can result in complete removal of the possible tumor, should be done as soon as possible.

C) Growth is slow and symptoms are caused by compression rather than tissue invasion. A meningioma is benign, encapsulated, and slow-growing. Sometimes the patient has no symptoms because of the slow-growing nature of the tumor.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? A) Limited attention span and forgetfulness B) Visual agnosia C) Lack of deep tendon reflexes D) Auditory agnosia

C) Lack of deep tendon reflex Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

The nurse educator is teaching nursing students about various types of brain tumors. The instructor recognizes that teaching has been effective when students correctly identify a client whose lab work indicates excessively high levels of thyroid stimulating hormone would most likely be diagnosed with which type of tumor? A) Angioma B) Neuroma C) Pituitary adenoma D) Glioblastoma

C) Pituitary adenoma Pituitary adenomas can increased production of several hormones including TSH, ACTH, growth hormone and prolactin. Excessive hormone production is not characteristic of the brain tumors identified in the alternate options.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? A) Age B) Weight C) Preexisting conditions D) Family history

C) Preexisting conditions Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

Postoperative nursing assessment for a patient who has had a mastoidectomy should include observing for facial paralysis, which might indicate damage to which cranial nerve? A) First B) Fourth C) Seventh D) Tenth

C) Seventh Injury to the seventh cranial nerve, also known as the facial nerve, is a complication of a mastoidectomy, although rare. Hearing loss of less than 30 dB is a more common complication.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? A) III B) IV C) V D) VI

C) V The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to A) control fever. B) control shivering. C) dehydrate the brain and reduce cerebral edema. D) reduce cellular metabolic demand.

C) dehydrate the brain and reduce cerebral edema.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A) "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." B) "Try to ambulate independently after about 24 hours." C) "Shampoo your hair every day for 10 days to help prevent ear infection." D) "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

D) "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry.

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer? A) "This test measures visual acuity." B) "This test measures how well your eyes move." C) "This test is to see how well your eyes are aging." D) "This test measures peripheral vision and detects gaps in the visual field."

D) "This test measures peripheral vision and detects gaps in the visual field."

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? A) Cranial nerve I B) Cranial nerve V C) Cranial nerve XI D) Cranial nerve XII

D) Cranial nerve XII Assessment of the movement of the tongue is cranial nerve XII . Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement.

When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as A) normal. B) flaccid. C) decorticate. D) decerebrate.

D) Decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The client has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the client has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? A) Edema to the head and a blackened eye B) Edema to the head with a large scalp laceration C) Edema to the head with fixed pupils D) Edema to the head with bruising of the mastoid process

D) Edema to the head with bruising of the mastoid process Battle's sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? A) Flat B) Turned onto the operative side C) Elevated no more than 10 degrees D) Elevated 30 degrees

D) Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? A) Administer antihistamines according to the physician's prescription B) Keep the room brightly lit and play soothing music in the background C) Help the client take a brisk walk around the testing area D) Encourage the client to drink liberal amounts of fluids

D) Encourage the client to drink liberal amounts of fluids The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: A) Coma B) Absence of brain stem reflexes C) Apnea D) Glasgow Coma Scale of 6

D) Glasgow Coma Scale of 6 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? A) Disturbed sensory perception (visual) B) Dressing or grooming self-care deficit C) Impaired verbal communication D) Risk for injury

D) Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? A) Left-sided stroke B) Right-sided stroke C) Cerebral aneurysm D) Transient ischemic attack

D) TIA A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign? A) A significant loss of central vision B) Diminished acuity C) Pain associated with a purulent discharge D) The presence of halos around lights

D) The presence of halos around lights Colored halos around lights is a classic symptom of acute-closure glaucoma.

The nurse is caring for a client with a skin lesion that is oozing. The surrounding skin is acutely inflamed. What type of dressing should the nurse apply? A) Occlusive B) Protective C) Passive D) Interactive

D) interactive

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: A) fluid resuscitation. B) infection. C) body image. D) pain management.

D) pain management. With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

Dermis is the ________ _________

true skin