Exam 2
A client has undergone a barium swallow test. Which would be an appropriate action by the nurse to ensure that the client does not retain any barium after a barium swallow?
Monitoring the stool passage and its color
The nurse on a cruise ship is assessing clients for motion sickness. Which is a common misconception regarding motion sickness?
Once symptoms occur, they will always be present.
The nurse is assisting the eye surgeon in completing an examination of a client's eye. Which piece of equipment would the nurse provide to the surgeon to examine the optic disc under magnification?
Ophthalmoscope
The nurse is caring for a client following a colonoscopy. During the procedure, two medium-sized polyps were removed. Which nursing assessment in the recovery area is a priority?
Vital signs
The nurse is obtaining a history on a client stating the inability to read the newspaper and seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?
Assess peripheral vision.
Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?
Audiologist
A nurse is caring for a client diagnosed with keratitis. What advice should the nurse give this client?
Begin using dark glasses.
The nurse is accompanying the client to the diagnostic imaging unit for a magnetic resonance imaging (MRI). Which action by the nurse is most important prior to the test?
Calculate drop per minute for intravenous fluids and infuse by gravity.
A nursing instructor is teaching pre-nursing students in a pathophysiology class. What would the instructor teach the students about Ménière disease?
It is referred to as endolymphatic hydrops.
The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. What does the nurse understand to be related to visual changes caused by aging?
Changes in accommodation
The nurse is examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract. Which would be the most important assessment for the nurse to make?
Checking if the mucous membranes are dry
Which nursing goal is a priority when caring for a client newly diagnosed with vertigo?
Client will remain safe while ambulating in the home.
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?
Client's tolerance for pain and discomfort
The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be accurate?
Conductive
A nurse is caring for a client immediately following cataract removal. Which symptom would be most alarming to the nurse?
Dry, tickling cough
The nurse is holding a teaching workshop on managing the symptoms of hiatal hernia in older adults. Which lifestyle modification should be included in the presentation?
Eliminating tobacco use
The nurse is assessing a client's eyes as part of the inspection part of the assessment process. For which reason does the nurse identify a normal variation in the angle of the lateral and medial canthus?
Ethnic differences
The nurse is caring for a client who just returned from a trip requiring an airline flight. The client reported ear pain upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?
Eustachian tube
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
A complete blood count including differential
A client comes to the walk-in clinic reporting feeling a "bug in my ear." What action should be taken when there is an insect in the ear?
Installation of mineral oil
A nurse is caring for a client who has undergone enucleation. What complication of enucleation should be addressed by the nurse?
Hemorrhage
The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis?
Identification of opacities on the lens
A client who is recovering from bariatric surgery is returning from the postanesthesia care unit. Which nursing assessment finding is of greatest concern in the immediate postoperative period for this client?
Impaired Gas Exchange
The nurse is obtaining a history from a client complaining of ear pain and dizziness. Which assessment finding is the best evidence that the client has a perforated eardrum?
Fluid draining in the external canal
A nurse is caring for a client scheduled for general anesthesia. Which assessment finding would contraindicate the use of atropine in this client?
Glaucoma
The occupational nurse is advising a client on options to enhance workplace communication because the client has progressive hearing loss. The client works as a customer service representative. In discussing the options with the client, which type would be the last option offered by the nurse?
Headsets with amplifiers
The nurse is caring for a client in the triage section of a walk-in clinic. Which triad of common symptoms suggests a diagnosis of Ménière disease?
Hearing loss, vertigo, tinnitus
The nurse is working with clients with digestive tract disorders. Which organ does the nurse realize has effects as an exocrine gland and an endocrine gland?
Pancreas
A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client?
Patchy flakes clinging to the eyelashes
The nurse is scheduling gastrointestinal (GI) diagnostic testing for a client. Which GI test should be scheduled first?
Radiography of the gallbladder
The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged?
Removing the cerumen by means of a cotton tip applicator
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?
Retinal Angiography
The nurse is obtaining a history from a client who indicates hearing loss due to drug toxicity. Which type of hearing loss is noted?
Sensorineural
There are several types of hearing loss. Which type of hearing loss benefits from the use of a hearing aid?
Sensorineural
The nurse is providing care to a client who has had a percutaneous liver biopsy. For what would the nurse monitor the client?
Signs and symptoms of bleeding
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting the assessment findings to the health care provider, which description is appropriate?
Signs and symptoms of conjunctivitis
The nurse is assessing a client for objective symptoms of hearing difficulties. Which sign leads the nurse to take alternate measures to ensure client understanding of teaching?
The client leans forward and turns the head.
The nurse is evaluating the independent care of a client recovering from a stapedectomy. Which action made by the client indicates a need for further teaching?
The client uses clean technique to clean the wound.
The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect?
The eighth cranial nerve
A client states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision?
The macula lutea
The nurse is caring for a client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?
The small intestine
An older adult client is scheduled for cataract surgery and asks the nurse, "Will I need to wear thick lenses after surgery?" Which is an appropriate response from the nurse?
"An implanted lens has replaced the need for corrective glasses."
At morning report, the nurse learns the assigned client is blind. Which question should the nurse ask the client upon initial assessment?
"Can you perceive light and motion?"
The nurse is caring for a client following gastrointestinal diagnostic testing. The client verbalizes feeling shame due to having frequent gas. Which nursing suggestion is best?
"Having gas following the procedure is normal. Expel the gas to decrease discomfort."
What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?
Tinnitus and sensorineural hearing loss
Which symptom reported by a client would the nurse relate to a tentative diagnosis of objective vertigo?
A sensation of things moving
The nurse is instructing the client on sensations commonly experienced when a contrast agent is injected into the body during diagnostic studies. Which sensation is most common?
A warm sensation
While cleaning gutters, a client reports getting debris in the eyes. On inspection, the nurse notes no obvious foreign object. Which diagnostic evaluation technique would be most beneficial for this client?
Administer fluorescein dye.
A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client?
To clear the dust and particles from the surface of the eyes
