exam 2 review

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A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition? a. hyperopia b. emmetropia c. myopia d. astigmatism

A

A client has undergone arthroscopy. After the procedure, the site where the arthroscope was inserted is covered with a bulky dressing. The client's entire leg is also elevated without flexing the knee. What is the appropriate nursing intervention required in caring for a client who has undergone arthroscopy? a. Apply a cold pack at the insertion site. b. Apply warm compresses to the insertion site. c. Provide a gentle massage. d. Assist with performing ROM exercises.

A

A client is examined due to recent vision changes and is diagnosed with myopia. What is the cause of this client's vision change? a. elongated eyeballs b. shortened eyeballs c. irregularly shaped corneas d. unequal curvatures in the cornea

A

A client is exhibiting diminished range of motion, loss of flexibility, stiffness, and loss of height. The history and physical findings are associated with age-related changes of which area? a. Joints b. Bones c. Muscles d. Ligaments

A

A nurse is obtaining a history from a new client with glaucoma. The client indicates having read about the diagnosis and understanding that this type of glaucoma is due to the degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the aqueous humor. The loss of absorption will lead to an increased resistance, and thus a chronic, painless buildup of pressure in the eye. Which type of glaucoma has the client described? a. open angle b. angle closure c. congenital d. secondary

A

A nurse is performing an eye examination. Which question would not be included in the examination? a. "Are you able to raise both eyebrows?" b. Have you experienced blurred, double, or distorted vision?" c. "Do any family members have any eye conditions?" d. "What medications are you taking?"

A

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? a. osteomyelitis b. hematoma c. hemorrhage d. infection

A

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? a. Myopia b. Astigmatism c. Hyperopia d. Emmetropia

A

The client with chronic open-angle glaucoma is receiving timolol (Timoptic) eye drops. Which evaluation finding would indicate to the nurse the treatment is working? a. Intraocular pressure 15 mm Hg b. Reduced peripheral vision c. Halos around lights d. Decrease in nausea and vomiting

A

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response? a. Decrease in estrogen b. Increase in calcitonin c. Decrease in parathyroid hormone d. Increase of vitamin D

A

The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client's lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse? a. Call the physician to inform them of the findings. b. Administer pain medication. c. Request an antihistamine for the allergic reaction. d. Increase the intravenous fluids for hemorrhage.

A

The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform? a. Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye b. Holds down the lower lid of the eye by applying pressure on the eyeball and the cheekbone c. Applies gentle pressure to the upper eyelid to keep the lid open while telling the client to gaze upward d. Applies firm pressure to the upper and lower eyelids at the outer edges to keep eyelids in approximation

A

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? a. Identification of opacities on the lens b. Identification of white circle around the cornea c. Identification of yellowish aging spot on the retina d. Identification of redness of the sclera

A

The nurse realizes that a client understands how to correctly instill ophthalmic medications when the client: a. pulls the tissue near the cheek downward to instill medication. b. wipes the lids and lashes prior to instillation in a direction toward the nose with moistened, soft gauze. c. allows the tip of the container to touch the eyelid while administering the medication. d. rubs the eye after administering medication.

A

The nurse recognizes that goal of treatment for metastatic bone cancer is to: a. Promote pain relief and quality of life b. Reconstruct the bone with a prosthesis c. Diagnose the extent of bone damage d. Cure the diseased bone and cartilage

A

To straighten the ear canal in an adult for examination, the nurse practitioner would grasp the auricle and pull it: a. Up and backward. b. Upward and outward. c. Slightly outward. d. Downward.

A

Which is not a risk factor for osteoporosis? a. being male b. small-framed, thin White or Asian women c. being postmenopausal d. family history

A

Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests? a. Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss b. Conducting various tests to determine the function and the structure of the eyes c. Determining if further action is warranted d. Advising the patient on the diet and exercise regimen to be followed

A

Which precautions should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance? a. Grasp the siderails when rising to a standing position. b. Keep his or her eyes closed. c. Refrain from looking at one place. d. Immobilize the head to reduce the risk of falling

A

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? a. "The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device." b. "The continuous passive motion device can decrease the development of adhesions." c. "Bleeding is a complication associated with the continuous passive motion device." d. "Monitoring skin integrity is important while the continuous passive motion device is in place."

A

Which terms refers to the progressive hearing loss associated with aging? a. Presbycusis b. Exostoses c. Otalgia d. Sensorineural hearing loss

A

Which would be contraindicated as a component of self-care activities for the client with a cast? a. Cover the cast with plastic to insulate it b. Cushioning rough edges of the cast with tape c. Elevate the casted extremity to heart level frequently d. Do not attempt to scratch the skin under a cast

A

A bone graft may be used for which of the following reasons? Select all that apply. a. Joint stabilization b. Defect filling c. Stimulation of bone healing d. Improvement of motion e. Reduction of a fracture

A, B, C

Which of the following are associated with compartment syndrome? Select all that apply. a. Trauma from accidents b. Surgery c. Casts d. Tight bandages e. Crushing injuries

A, B, C, D, E

A nurse is caring for a client who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.) a. Encouraging the client to care for the residual limb b. Allowing the client to express grief c. Encouraging the client to have family and friends view the residual limb to decrease self-consciousness d. Encouraging family and friends to refrain from visiting temporarily because this may increase the client's embarrassment e. Introducing the client to local amputee support groups

A, B, E

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment? a. To hasten formation of scar tissue b. To prevent vision loss c. To eliminate the need for medical care d. To serve as a stopgap measure until help arrives

B

A client diagnosed with a cataract comes into the clinic. What assessments should the nurse observe in this client? a. A burning sensation and the sensation of an object in the eye b. Blurred or cloudy visual image c. Inability to produce sufficient tears d. A swollen lacrimal caruncle

B

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing: a. Opacity in the lens. b. Loss of accommodative power in the lens. c. Shrinkage of the vitreous body. d. Decreased eye muscle tone

B

A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which exercise would the nurse be most likely to suggest? a. Yoga b. Walking c. Bicycling d. Swimming

B

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort? a. High-Fowler's to allow for maximum hip flexion b. Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees c. Prone, with a pillow under the shoulders d. Supine, with the bed flat and a firm mattress in place

B

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? a. Compartment syndrome b. Fat embolism c. Infection d. Volkmann's ischemic contracture

B

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

An unresponsive client had a plaster cast applied to the right lower leg 8 hours ago. When moving the client, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse? a. Document the findings. b. Notify the physician. c. Remove the cast immediately. d. Assess for pedal pulse and mobility of toes.

B

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client? a. Disseminated intravascular coagulation b. Compartment syndrome c. Carpal tunnel syndrome d. Fat embolism syndrome

B

The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately? a. Chalazion b. Acute angle-closure glaucoma c. Hordeolum d. Blepharitis

B

The nurse is educating a client with low back pain on proper lifting techniques. The nurse recognizes that the education was effective when the client a. reaches over the head with the arms fully extended. b. places the load close to the body. c. uses a narrow base of support. d. bends at the hips and tightens the abdominal muscles

B

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

Which symptom is related to vertigo? a. Loss of consciousness b. Spinning sensation c. Fainting d. Syncope

B

Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.) a. "You may cross your legs at the ankles only." b. "Place pillows between your legs when you lay on your side." c. "Avoid bending forward when sitting in a chair." d. "Use a raised toilet seat and high-seated chair." e. "It is okay to briefly flex the hip to put on your clothes."

B, C, D

A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate? a. "Most clients need to use the drops for only about a few months." b. "If the drops don't work, surgery may be needed to cure your condition." c. "You'll need to use the drops for the rest of your life to control the glaucoma." d. "These drops are just the first step to make sure that your vision doesn't get worse."

C

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? a. External ear b. Middle ear c. Inner ear d. Tympanic membrane

C

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: a. provide instructions on eye patching. b. assess the client's visual acuity. c. demonstrate eyedrop instillation. d. teach about intraocular lens cleaning.

C

A client is diagnosed with carpal tunnel syndrome. Which assessment findings would the nurse expect? a. Pain radiating down the dorsal surface of the forearm b. Tenderness in the affected wrist c. Inability to flex index and middle fingers d. A decrease in grasp strength

C

A client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. What complication should the nurse interpret as the findings? a. Avascular necrosis b. Fat embolism c. Osteomyelitis d. Compartment syndrome

C

A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect? a. Infection b. Pulmonary embolism c. Avascular necrosis d. Hypovolemic shock

C

A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which of the following describes the desired effects of this procedure? a. Reverse optic nerve damage b. Restore vision c. Improve outflow drainage d. To relieve pain

C

A healthcare provider asks a nurse to test a client for Tinel's sign to diagnose carpal tunnel syndrome. What should the nurse do to perform this assessment? a. Have the client make a fist and open the hand against resistance. b. Have the client stretch the fingers around a ball and squeeze with force. c. Have the client hold the palm of the hand up while the nurse percusses over the median nerve. d. Have the client pronate the hand while the nurse palpates the radial nerve.

C

After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. Which client statement indicates that the outcome of the teaching plan has been met? a. "I need to wear sunglasses for the first 3 to 4 days even when I'm inside." b. "Dots or flashing lights in my vision are to be expected for the first few days." c. "I should avoid pulling or pushing any object that weighs more than 15 lbs." d. "I need to keep the eye patch on for about a week after surgery."

C

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

The nurse assesses soft subcutaneous nodules along the line of the tendons in a patient's hand and wrist. What does this finding indicate to the nurse? a. The patient has osteoarthritis. b. The patient has lupus erythematosus. c. The patient has rheumatoid arthritis. d. The patient has neurofibromatosis

C

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has sustained a fracture. The nurse suspects which complication? a. Compartment syndrome b. Hypovolemic shock c. Fat embolism syndrome d. Reflex sympathetic dystrophy syndrome

C

The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided? a. "I will lie prone with my legs slightly elevated." b. "I will bend at the waist when I am lifting objects from the floor." c. "I will avoid prolonged sitting or walking." d. "Instead of turning around to grasp an object, I will twist at the waist."

C

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? a. Ultrasonography b. Retinal Imaging c. Retinal Angiography d. Retinoscopy

C

The nurse is evaluating a client's peripheral neurovascular status. Which would the nurse report to the health care provider as a circulatory indicator of peripheral neurovascular dysfunction? a. Weakness b. Paresthesia c. Cool skin d. Paralysis

C

The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. The client is visually impaired. Which of the following would be most appropriate for the nurse to do when interacting with the client? a. Talk to the client in a loud tone of voice. b. Avoid using the terms "see" or "look." c. Face the client when speaking directly to him. d. Touch the client before identifying himself or herself.

C

Which factor inhibits fracture healing? a. Vitamin D b. Exercise c. Local malignancy d. Maximum bone fragment contact

C

Which of the following factors would the nurse need to keep in mind about the focus of the initial history when assessing a new client with a musculoskeletal problem? a. Client's age b. Client's lifestyle c. Any chronic disorder or recent injury d. Duration and location of discomfort or pain

C

Which type of glaucoma presents an ocular emergency? a. Normal tension glaucoma b. Ocular hypertension c. Acute angle-closure glaucoma d. Chronic open-angle glaucoma

C

You are doing discharge teaching with a client after a stapedectomy. Why would it be important for you to advise the client to refrain from blowing the nose? a. It may cause sudden headaches. b. It may cause vertigo. c. It may dislodge the prosthesis. d. It may cause excessive drainage.

C

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse? a. "Your left toes have been amputated." b. "The pain is really from the nerves in the upper leg." c. "Pain medication usually does not help this type of pain." d. "Describe the pain and rate it on the pain scale."

D

A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall? a. Impacted fracture b. Transverse fracture c. Compound fracture d. Pathologic fracture

D

A health care provider diagnoses primary osteoporosis in a client who has lost bone mass. For which client is primary osteoporosis most common? a. elderly man b. young child c. young menstruating woman d. elderly postmenopausal woman

D

A nurse is caring for a client who recently underwent a total hip replacement. What is the best action by the nurse for client care? a. Ease the client onto a low toilet seat. b. Allow the client's legs to be crossed at the knees when out of bed. c. Use soft chairs when the client is sitting out of bed. d. Limit hip flexion of the client's hip when the client sits up

D

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy, and the immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client? a. The nurse caring for this client is also caring for four other immunosuppressed clients on the medical floor. b. The nurse caring for this client is also caring for four clients receiving chemotherapy for cancer treatment on the oncology floor. c. The nurse caring for this client is also caring for two other immunosuppressed clients on the medical intensive care unit. d. The nurse is caring for this client on the intensive care unit.

D

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 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

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder? a. Age younger than 40 years b. Hyperopia since age 20 years c. History of respiratory disease d. Prolonged use of corticosteroids

D

The ophthalmologist tells a patient that he has increased intraocular pressure (IOP). The nurse understands that increased pressure resulting from optic nerve damage is indicated by a reading of: a. 0 to 5 mm Hg. b. 6 to 10 mm Hg. c. 11 to 20 mm Hg. d. >21 mm Hg

D

A nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan? a. Examine the surgical dressing every hour. b. Administer pain medication per client request. c. Monitor vital signs every 4 hours. d. Perform neuromuscular assessment every hour.

D.


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