Final question collection
A client who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The client asks the nurse what these numbers specifically mean. What is a correct response by the nurse? "A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away." "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." "A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away." "A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away."
"A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." Explanation: The Snellen chart is a tool used to measure visual acuity. It is composed of a series of progressively smaller rows of letters and is used to test distance vision. The fraction 20/20 is considered the standard of normal vision. Most people can see the letters on the line designated as 20/20 from a distance of 20 feet. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.
A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? "This condition is most likely due to a stroke that the patient didn't realize he had." "A specific gene is involved in the development of this disorder." "Evidence shows that there are changes in nerve cells and brain chemicals." "The numerous drugs that he was taking contributed to his current confusion."
"Evidence shows that there are changes in nerve cells and brain chemicals." Explanation: Specific neuropathologic and biochemical changes are found in patients with Alzheimer's disease. These include neurofibrillary tanges and neuritic plaques as well as altered neurotransmitter function, specifically acetylcholine. Vascular dementia is associated with a subclinical stroke. Although genetics is being studied as an underlying mechanism for Alzheimer's disease, no specific gene or gentic marker has been identified. Delirium is often the result of the interaction or use of multiple drugs.
A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding? "I need to call the doctor if I get nauseated." "I need to call the doctor if I have a light morning discharge." "I need to call the doctor if I get a scratchy feeling." "I need to call the doctor if I see flashing lights."
"I need to call the doctor if I see flashing lights." Explanation: Postoperatively, the client who has undergone cataract extraction with intraocular lens implant should report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the ophthalmologist. Slight morning discharge and a scratchy feeling can be expected for a few days. Blurring of vision may be experienced for several days to weeks.
The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? "I'm planning to avoid exposure to direct sunlight on my next vacation." "I've never exercised regularly, but I'm going to start working out at the gym daily." "I'm planning to talk with my pharmacist to review my current medications." "I'm certainly going to keep a close eye on my blood pressure from now on."
"I'm certainly going to keep a close eye on my blood pressure from now on." Explanation: Hypertension is a major cause of vision loss, exceeding the significance of inactivity, sunlight, and adverse effects of medications.
A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include? "This drug will help to stop the disease from getting worse." "Once it becomes effective, you can stop the drug." "The drug helps to control the symptoms of the disease." "The client need to take this drug for the rest of his or her life."
"The drug helps to control the symptoms of the disease." Explanation: Donepezil hydrochloride is a cholinesterase inhibitor used to control symptoms of Alzheimer's disease. It does not cure or slow progression. Typically cognitive ability improves within 6 to 12 months of therapy, but if stopped, cognitive progression occurs. It is recommended that treatment continue at least through the moderate stage of the illness. However, it usually is not prescribed as life-long therapy.
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? "Dementia is a terrible disease of the elderly." "The most common cause of dementia in the elderly is Alzheimer's disease." "Drug interactions are the most common cause of dementia in the elderly." "Depression may manifest as dementia in elderly clients."
"The most common cause of dementia in the elderly is Alzheimer's disease." Explanation: The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's disease. Depression is common in elderly clients, but it doesn't cause dementia.
A 56-year-old client has come to the clinic for his routine eye examination and is told he needs bifocals. The client asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond? "You know, you are getting older now and we change as we get older." "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry." "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." "The eye gets shorter, back to front, as we age and it changes how we see things."
"There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." Explanation: As a result of a loss of accommodative power in the lens with age, many adults require bifocals or other forms of visual correction. This is not attributable to a change in the shape of the ocular globe. The nurse should not dismiss or downplay the client's concerns.
The nurse is teaching the client to instill eye drops. Which statement is correct? "Wash your hands before and after instilling eye drops and do not touch the tip of the bottle." "Eye drops are to be administered after eye ointments." "Wait 10 minutes between administering different eye ointments; you do not need to wait between administering different eye drops." "Eye drops may be administered with contact lenses in place."
"Wash your hands before and after instilling eye drops and do not touch the tip of the bottle." Explanation: Eye medications should be administered using an aseptic technique. Therefore, handwashing and not contaminating the tip of the medication container is important. Eye drops are administered after eye ointments, not before. The waiting time between administering eye ointments is 10 minutes. The client should also be taught to wait 5 minutes between the instillation of different eye drops. Contact lenses should be removed before eye drops or ointment is applied.
A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds: "What precipitates the outbursts?" "You need to remain calm during the outbursts." "Play quiet music that your grandmother may like." "Start rubbing her shoulders and her back."
"What precipitates the outbursts?" Explanation: A client with Alzheimer's disease may respond to exciting or confusing events with a catastrophic reaction, such as screaming, crying, or becoming abusive. The nurse needs to assess the situation and what precipitates the catastrophic reactions to best address how to prevent these events. Other nursing interventions include telling the client's granddaughter to remain calm and to distract the grandmother with quiet music, stroking, or both.
The nurse should recognize the greatest risk for the development of blindness in which of the following clients? A 58-year-old Caucasian woman with macular degeneration A 28-year-old Caucasian man with astigmatism A 58-year-old black woman with hyperopia A 28-year-old black man with myopia
A 58-year-old Caucasian woman with macular degeneration Explanation: The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts. The 58-year-old Caucasian woman with macular degeneration has the greatest risk for the development of blindness related to her age and the presence of macular degeneration. Individuals with hyperopia, astigmatism, and myopia are not in a risk category for blindness.
A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what? Slight morning discharge from the eye Any appearance of redness of the eye A "scratchy" feeling in the eye A new floater in vision
A new floater in vision Explanation: Cataract surgery increases the risk of retinal detachment and the client must be instructed to notify the surgeon of new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days after surgery.
A patient is being seen in the ophthalmology clinic for a suspected detached retina. What clinical manifestations does the nurse recognize as significant for a retinal detachment? Select all that apply. A visual field of floating particles A definite area of blank vision Momentary flashes of light Pain Halos around the eyes
A visual field of floating particles A definite area of blank vision Momentary flashes of light Explanation: Patients may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Patients do not complain of pain. Halos around the eyes are associated with glaucoma, not retinal detachment.
A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Passive range-of-motion exercises to prevent contractures Supine positioning Early initiation of physical therapy Absolute bed rest in a quiet, nonstimulating environment
Absolute bed rest in a quiet, nonstimulating environment Explanation: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.
Which type of glaucoma presents an ocular emergency? Acute angle-closure glaucoma Normal tension glaucoma Ocular hypertension Chronic open-angle glaucoma
Acute angle-closure glaucoma Explanation: Acute angle-closure glaucoma results in rapid progressive visual impairment. Normal tension glaucoma is treated with topical medication. Ocular hypertension is treated with topical medication. Chronic open-angle glaucoma is treated initially with topical medications, with oral medications added at a later time.
A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. Obtain a blood type and cross-match Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics Place the client in positive pressure isolation
Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics Explanation: Clients with meningitis require antipyretics and analgesia to treat fever and pain. As well, their neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised.
When performing the Weber test, where would the nurse place the vibrating tuning fork? Identify the area
After striking the tuning fork to produce vibration, the nurse would place the tuning fork on the patient's head or forehead to assess for bone condution using the Weber test.
A client has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action? Reassure the client that this is an age-related change in vision. Arrange for the client to have her visual acuity assessed. Arrange for the client to be assessed for macular degeneration. Facilitate tonometry testing.
Arrange for the client to be assessed for macular degeneration. Explanation: The Amsler grid is a test often used for clients with macular problems, such as macular degeneration. Distortions would not be attributed to age-related changes and there is no direct need for testing of intraocular pressure or visual acuity.
The nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-administer these medications safely and effectively? Assess the client for any previous inability to self-manage medications. Ask the client to demonstrate the instillation of her medications. Determine whether the client can accurately describe the appropriate method of administering her medications. Assess the client's functional status.
Ask the client to demonstrate the instillation of her medications. Explanation: The client or the caregiver at home should be asked to demonstrate actual eye drop administration. This method of assessment is more accurate than asking the client to describe the process or determining earlier inabilities to self-administer medications. The client's functional status will not necessarily determine the ability to administer medication safely.
Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response? Assess the grandmother for adventitious lung sounds Inform the family that this is a result of aging Administer donepezil every day Recommends placement of the grandmother in a nursing home
Assess the grandmother for adventitious lung sounds Explanation: Sudden onset of confusion may be the first symptom of an infection, such as pneumonia or urinary tract infection. The nurse needs to fully assess the situation before acting (such as telling the family this is a result of aging). Donepezil is used for Alzheimer's disease, which does not have acute onset. A recommendation for placement in a nursing home is premature without a full assessment at this time.
A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home? Maintain bed rest for 1 week. Lie on the stomach while sleeping. Avoid bending the head below the waist. Lift weights to increase muscle strength.
Avoid bending the head below the waist. Explanation: The nurse should encourage the patient to avoid bending or stooping for an extended period. Keep activity light. Avoid lying on the side of the affected eye the night after surgery. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
A client diagnosed with a cataract comes into the clinic. What assessments should the nurse observe in this client? A burning sensation and the sensation of an object in the eye Blurred or cloudy visual image Inability to produce sufficient tears A swollen lacrimal caruncle
Blurred or cloudy visual image Explanation: When a cataract forms, the light is blocked from reaching the macula and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle.
A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes Flexor spasm, clonus, and negative Babinski reflex Blurred vision, intention tremor, and urinary hesitancy Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Blurred vision, intention tremor, and urinary hesitancy Explanation: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski reflex is found in MS. Abdominal reflexes are absent with MS.
Which is a correct rationale for encouraging a client with otitis externa to eat soft foods? Chewy foods, such as red meat, may react with prescribed analgesics and antibiotics. Chewing may cause discomfort. Chewing may lead to further complications, such as otitis media. Chewing may cause excessive drainage.
Chewing may cause discomfort. Explanation: 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.
The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? Potassium-sparing diuretics Cholinergics Antibiotics Loop diuretics
Cholinergics Explanation: Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not used in the management of glaucoma.
A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? The nursing staff should rely on the family to assist with care because family members know the client best. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. As long as the client receives the ordered medication, special care measures aren't necessary. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.
Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. Explanation: The charge nurse should inform the new nurse that clients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment takes top priority. Families are an important part of the client care team; however, they shouldn't be relied upon to deliver care. Family members may take turns sitting with the hospitalized client to help maintain client safety. All procedures should be explained in simple terms that the client can understand. Medications should be administered as ordered; however, they don't typically improve symptoms. Instead, they slow disease progression.
A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache? Initiating a patient-controlled analgesia (PCA) of morphine sulfate Administering hydromorphone IV as needed Dimming the lights and reducing stimulation Distracting the client with activity
Dimming the lights and reducing stimulation Explanation: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patient's pain.
Postoperative health teaching for a patient who has had an intraocular lens implant is a vital nursing responsibility. Which of the following statements applies to this situation? Select all that apply. Avoid lying on the side of the affected eye for 72 hours. Avoid shampooing your hair for 48 hours. Do not lift, pull, or push objects heavier than 15 pounds. Wipe the closed eye from the inner canthus outward. Avoid bending the head forward for an extended time.
Do not lift, pull, or push objects heavier than 15 pounds. Wipe the closed eye from the inner canthus outward. Avoid bending the head forward for an extended time. Explanation: Hair shampooing may resume in 24 hours, if done cautiously. It is only necessary to avoid lying on the side of the affected eye for the first night after surgery. Refer to Box 49-7 in the text.
A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to Encourage the mother to take responsibility for cooking and cleaning the house. Ensure that the mother does not have access to car keys or drive an automobile. Allow the mother to smoke cigarettes outside on the porch without supervision. Turn off lights at night so that the mother differentiates night and day.
Ensure that the mother does not have access to car keys or drive an automobile. Explanation: A person with Alzheimer's disease needs to be provided with a safe environment. Driving is prohibited. Cooking and cleaning may be too much stimulation and place the client in danger. Daily activities must be simplified, short, and achievable. Smoking is allowed only with supervision. The person needs adequate lighting, and nightlights are helpful, particularly if the person has increased confusion at night.
Bell palsy is a disorder of which cranial nerve? Trigeminal (V) Vestibulocochlear (VIII) Facial (VII) Vagus (X)
Facial (VII) Explanation: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia is a disorder of the trigeminal nerve and causes facial pain. Meniere syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barre syndrome is a disorder of the vagus nerve.
An elderly client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which of the following symptoms to be exhibited in this client? Select all that apply. Flashing lights Cobwebs in vision field Complete loss of vision in both eyes Loss of central vision Eye pain Arcus senilis
Flashing lights Cobwebs in vision field Explanation: Many clients with detached retina experience a sensation of a curtain or veil lowering over vision field, flashing of lights, floaters, cobwebs, or spots. Complete vision loss can occur in the affected eye. Loss of central vision, eye pain, and arcus senilis is not indicated in this disorder.
A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client? Generously flush the affected eye with a dilute antibiotic solution. Generously flush the affected eye with normal saline or water. Apply a patch to the affected eye. Apply direct pressure to the affected eye.
Generously flush the affected eye with normal saline or water. Explanation: Chemical burns of the eye should be immediately irrigated with water or normal saline to flush the chemical from the eye. Antibiotic solutions, lubricant drops, and other prescription drops may be prescribed at a later time. Application of direct pressure may extend the damage to the eye tissue and should be avoided. Patching will be incorporated into the treatment plan at a later time to assist with the process of re-epithelialization, but at this point in the care of the client, patching will prevent irrigation of the eye.
A 6-year-old is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? Handwashing can prevent the spread of the disease to others. The importance of compliance with antibiotic therapy Signs and symptoms of complications, such as meningitis and septicemia The likely need for surgery to prevent scarring of the conjunctiva
Handwashing can prevent the spread of the disease to others. Explanation: The nurse must inform the parents and child that viral conjunctivitis is highly contagious and instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths, and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy. Clients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not associated with viral conjunctivitis.
The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? Communication difficulties Separation from others Personality changes Impaired memory
Impaired memory Explanation: Patients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. They also exhibit impulsivity, which increases their risk. Maintaining a safe environment takes top priority. Communication difficulties could be the basis for several nursing diagnoses such as impaired verbal communication, powerlessness, and impaired social interaction. Separation from others could lead to social isolation, impaired social interaction, and social isolation. Personality changes may lead to a risk for self- or other directed violence, chronic low self-esteem, and risk for suicide.
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? All at one time, to provide a longer rest period Before meals, to stimulate her appetite In the morning, with frequent rest periods Before bedtime, to promote rest
In the morning, with frequent rest periods Explanation: Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the client may be too exhausted to eat. Procedures should be avoided near bedtime if possible.
A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? Instill the medication in the conjunctival sac. Maintain a supine position for 10 minutes after administration. Keep the eyes closed for 1 to 2 minutes after administration. Apply the medication evenly to the sclera
Instill the medication in the conjunctival sac. Explanation: Eye drops should be instilled into the conjunctival sac, where absorption can best take place, rather than distributed over the sclera. It is unnecessary to keep the eyes closed or to maintain a supine position after administration.
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside? Nebulizer and thermometer Intubation tray and suction apparatus Blood pressure apparatus Incentive spirometer
Intubation tray and suction apparatus Explanation: Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.
A colleague has been splashed in the eye with cleaning solution. Which of the following would be the priority? Finding out what the substance was Irrigating the eye immediately with tap water Covering the eye with a clean sterile dressing Instilling a local anesthetic into the eye
Irrigating the eye immediately with tap water Explanation: With any ocular burn, the priority is to irrigate the eye with tap water immediately. While or after this is done, information about the substance can be obtained. A local anesthetic is instilled, particulate matter is removed, and irrigation continues until the pH normalizes. Then antibiotics are instilled and the eye is patched.
Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? Arrange for the administration of prophylactic antibiotics to unaffected residents. Instill normal saline into the eyes of affected residents two to three times daily. Swab the conjunctiva of unaffected residents for culture and sensitivity testing. Isolate affected residents from residents who have not developed conjunctivitis.
Isolate affected residents from residents who have not developed conjunctivitis. Explanation: To prevent spread during outbreaks of conjunctivitis caused by adenovirus, health care facilities must set aside specified areas for treating clients diagnosed with or suspected of having conjunctivitis caused by adenovirus. Antibiotics and saline flushes are ineffective and normally there is no need to perform testing of individuals lacking symptoms.
The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care? Limit foods that are high in sodium. Encourage intake of caffeinated fluids. Administer prescribed antihistamine. Restrict high-potassium foods.
Limit foods that are high in sodium. Explanation: Sodium and fluid retention disrupts the delicate balance between the endolymph and perilymph in the inner ear. Therefore, many clients can control their symptoms by adhering to a low-sodium diet. Caffeinated fluids are to be avoided because of their diuretic effect. Diuretics, not antihistamines, would be prescribed to lower the pressure in the endolymphatic system. Foods high in potassium would be encouraged if the client is prescribed a diuretic that causes potassium loss.
A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the client's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the client's plan of care? Elevate the head of the bed to 75 degrees. Maintain the client on complete bed rest. Administer enemas when the client is constipated. Leg exercises to prevent deep vein thrombosis
Maintain the client on complete bed rest. Explanation: Cerebral aneurysm precautions are implemented for the client with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity (such as leg exercises), pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted. The head of the bed is elevated 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the client remains flat to increase cerebral perfusion. No enemas are permitted, but stool softeners and mild laxatives are prescribed.
The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? Maintaining the client's functional independence Providing health education Monitoring neurologic status closely Promoting mobility
Monitoring neurologic status closely Explanation: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply. Possible nursing home placement Pain associated with physical therapy Increasing disability Becoming a burden on the family Loss of appetite
Possible nursing home placement Increasing disability Becoming a burden on the family Explanation: Elderly clients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite.
Some clients with acoustic neuromas have vertigo. What is a priority nursing action for clients with vertigo? Protect the client from injury. Provide small meals of tepid food. Mobilize the client at every opportunity. Provide ice to the affected ear.
Protect the client from injury. Explanation: For clients with vertigo, the nurse takes measures to protect the client from injury. Nursing actions do not include providing small meals of tepid food, mobilizing the client at every opportunity, or providing ice to the affected ear.
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? Provide a board of commonly used needs and phrases. Have the client speak to loved ones on the phone daily. Help the client complete his or her sentences as needed. Speak in a loud and deliberate voice to the client.
Provide a board of commonly used needs and phrases. Explanation: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? Respiratory Gastrointestinal Urinary Skin
Respiratory Explanation: Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority.
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? Relocation stress syndrome related to hospitalization Defensive coping related to diagnosis of Alzheimer's disease Risk for caregiver role strain related to increased client care needs Decisional conflict related to lack of relevant treatment information
Risk for caregiver role strain related to increased client care needs Explanation: The client's spouse is at risk for caregiver role strain because the client has started to exhibit care needs beyond the spouse's capacity to provide. A diagnosis of Relocation stress syndrome may be appropriate for a client with inadequate preparation for hospital admission, transfer, or discharge; however, this client is confused and may be unable to grasp the meaning of such preparation. The spouse, on the other hand, is more likely to be relieved, at least physically, and able to rest because of the client's admission. Defensive coping and Decisional conflict aren't pertinent nursing diagnoses in this situation because the client's spouse is aware of and has accepted the client's disease.
A patient presents to an eye clinic with a number of symptoms related to his diminished vision. An initial history leads the nurse practitioner to suspect that the patient has acute angle-closure glaucoma. Which of the following symptoms would apply to this diagnosis? Select all that apply. Severe eye pain Tunnel vision Reddening of the eye Gradual loss of peripheral vision Sudden onset of visual disturbance Nausea and vomiting
Severe eye pain Reddening of the eye Sudden onset of visual disturbance Nausea and vomiting Explanation: Gradual loss of peripheral vision, usually in both eyes, and tunnel vision in advanced stages are symptoms of primary open-angle glaucoma.
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 to the physician the assessment findings, which word is appropriate? Signs and symptoms of conjunctivitis Signs and symptoms of ptosis Signs and symptoms of nystagmus Signs and symptoms of proptosis
Signs and symptoms of conjunctivitis Explanation: Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes. Ptosis is drooping of the upper eyelid. Proptosis is an extended and upper eyelid that delays in closing or remains partially open. Nystagmus is an uncontrolled oscillating movement of the eyeball.
A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client? Sit or stand in front of the client when speaking. Use exaggerated lip and mouth movements when talking. Stand in front of a light or window when speaking. Say the client's name loudly before starting to talk.
Sit or stand in front of the client when speaking. Explanation: Standing directly in front of a hearing-impaired client allows him or her to lip-read and see facial expressions that offer clues to what is being said. Using exaggerated lip and mouth movements can make lip-reading more difficult by distorting words. Backlighting can create glare, making it difficult for the client to lip-read. To get the attention of a hearing-impaired client, gently touch the client's shoulder or stand in front of the client.
A client with Meniere's disease has a nursing diagnosis of risk for injury related to gait disturbances and vertigo. Which of the following would be most appropriate to include in this client's plan of care? Moving the head from side-to-side when vertigo occurs Sitting down at the first sign of feeling dizzy Closing the eyes when lying down during an episode of vertigo Performing self-care activities when the vertigo first starts
Sitting down at the first sign of feeling dizzy Explanation: For a nursing diagnosis of risk for injury, the client should sit down at the first sign of feeling dizzy. The client also should place a pillow on each side of the head to avoid movement, keep the eyes open, and stare straight ahead when lying down and perform self-care activity during vertigo-free periods.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? Take small meals of soft consistency Increase the intake of calcium and proteins. Include additional servings of fruits and raw vegetables Include fish, liver, and chicken in diet
Take small meals of soft consistency Explanation: To help a client with trigeminal neuralgia, who suffers pain in the jaws meet his or her nutritional needs, the nurse should offer small meals of soft consistency. Foods may be pureed to minimize jaw movements when eating. There is no need for the client to increase the intake of fruits and raw vegetables, calcium, or proteins during trigeminal neuralgia. The nurse should avoid offering meat and fish in the diet because they require excessive chewing by the client.
A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the client? The client should discuss this new remedy with her ophthalmologist promptly. The client should monitor her IOP closely for the next several weeks. The client should do further research on the herbal remedy. The client should report any adverse effects to her pharmacist.
The client should discuss this new remedy with her ophthalmologist promptly. Explanation: Clients should discuss any new treatments with an ophthalmologist; this should precede the client's own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not possible.
You are admitting a 30-year-old who has a hearing impairment. The client is accompanied by family members. What information would be important to ask the family members to help you care for your client? How the client lost their hearing What allergies the client has The client's preferred method of communication How much the client weighs
The client's preferred method of communication Explanation: Some clients with hearing deficits learn sign language, a method for communication that uses a hand-spelled alphabet and word symbols. Clients also learn speech reading, also called lip reading. Knowing when the client lost their hearing, or what allergies the client has or how much the client weighs will not help you communicate, thereby, care for the client better.
The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client? To minimize the adverse effects of drug therapy To reduce the magnitude of the hearing deficit To minimize the risk of a tumor that involves the vestibulocochlear nerve To reduce the production of fluid in the inner ear
To reduce the production of fluid in the inner ear Explanation: A low-sodium diet lessens edema. This measure does not help minimize the adverse effects of drug therapy, reduce the magnitude of the hearing deficit, or minimize the risk of a tumor that involves the vestibulocochlear nerve.
A client at an extended-care facilty who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include Walking the client in the facility yard during the day Allowing the client to take a 2-hour nap in the afternoon Providing a glass of warm milk for breakfast Having the client sit at the nurse's station during night-time hours
Walking the client in the facility yard during the day Explanation: Regular exercise during the day will enhance sleep at night for clients with Alzheimer's disease. Another activity that helps for interrupted sleep, inability to fall asleep, or both is drinking warm milk at night. The nurse should discourage excessive sleep during the day. Sitting at the nurse's station may be too stimulating at night-time hours.
A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse? Write down the steps of the procedure for the patient to read before beginning the treatment. Change the dressing while the patient is reading the steps of the treatment because distraction decreases anxiety. Use nonverbal signals of agreement (head nodding), even if unsure, to instill confidence and trust. Minimize misunderstandings by completing the patient's sentences (e.g., fill-in-the-blanks) to decrease the patient's embarrassment.
Write down the steps of the procedure for the patient to read before beginning the treatment. Explanation: Written communication is an excellent resource and means of mutual understanding. Distraction is not appropriate because a hearing-impaired person needs the care provider's full attention. Do not pretend to understand or complete the person's sentences for them.
What would the nurse correctly identify as the structure that responds to light through constriction and dilation.
pupil The pupil is the structure that responds to light by constricting and dilating. The lens lies directly behind the pupil and allows for focusing.
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: stay with the client and encourage him to eat. help the client fill out his menu. give the client privacy during meals. fill out the menu for the client.
stay with the client and encourage him to eat. Explanation: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.
A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to: forget to eat. not change his position often. exhibit acquiescent behavior. wander.
wander. Explanation: A client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing him closer to the nurses' station makes it easier to monitor him and better ensures his safety if he begins to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change his position often, or modify his behavior.
