RN 200 Exam 2

Which intervention would be part of the plan of care for a patient who has new vision loss? a. Allow the patient to express feelings of grief and anger. b. Have the UAP perform all self-care activities for the patient. c. Address any family present first when discussing care concerns. d. Speak loudly and clearly, addressing the patient with each contact.

a. Allow the patient to express feelings of grief and anger.

The patient who has a conductive hearing loss a. hears better in a noisy environment. b. hears sound but does not understand speech. c. often speaks loudly because his or her own voice seems low. d. has clearer sound with a hearing aid if the loss is less than 30 dB.

a. hears better in a noisy environment.

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A. Increase intake of deep yellow and orange vegetables. B. Administer eye drops twice daily. C. Avoid bending at the waist. D. Wear an eye patch at night.

a. increase intake of deep yellow and orange vegetables (vitamins, carotene)

When teaching a patient with melanoma about this disorder, the nurse recognizes that the patient's prognosis is most dependent on a. the thickness of the lesion. b. the degree of asymmetry in the lesion. c. the amount of ulceration in the lesion. d. how much the lesion has spread superficially.

a. the thickness of the lesion.

Always assess the patient with an eye problem for a. visual acuity. b. pupillary reactions. c. intraocular pressure. d. confrontation visual fields.

a. visual acuity.

A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist gauze dressings. How would the nurse expect healing to occur? a. Cell regeneration b. Tertiary intention c. Secondary intention d. Remodeling of tissues

c. Secondary intention

An 82year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

c. Stage 3

The most important intervention for the patient with epidemic keratoconjunctivitis is a. cleansing the affected area with baby shampoo. b. monitoring spread of infection to the opposing eye. c. regular instillation of artificial tears to the affected eye. d. teaching the patient and caregivers good hygiene techniques.

d. teaching the patient and caregivers good hygiene techniques.

A patient reports tinnitus and balance problems. The medication that may be responsible is a. digoxin. b. warfarin. c. furosemide. d. acetaminophen.

C. furosemide.

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days." B. "You need to tilt your head back when washing your hair." C. "You can get water in your eyes in 1 day." D. "You need to limit your housekeeping activities."

D. "You need to limit your housekeeping activities."

A nurse is caring for a client who has regular occupational exposure to sunlight and presents for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose C. A raised, circumscribed lesion on the face that contains yellow-whig purulent material D. An irregularly shaped brown lesion with light blue areas on the neck

D. An irregularly shaped brown lesion with light blue areas on the neck

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing.

D. Granulation tissue fills the wound during healing.

What should be included in the discharge teaching for the patient who had cataract surgery (select all that apply)? a. Eye discomfort is often relieved with mild analgesics. b. A decline in visual acuity is common for the first week. c. Stay on bed rest and limit activity for the first few days. d. Notify the provider if an increase in redness or drainage occurs. e. Following activity restrictions is essential to reduce intraocular pressure

A D E

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. "I should restrict rapid movements and avoid bending from the waist for several weeks." B. "I should wait until the day after surgery to wash my hair." C. "I will remove the dressing behind my ear in 7 days." D. "My hearing should be back to normal right after surgery

A. "I should restrict rapid movements and avoid bending from the waist for several weeks."

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear. B. Air conduction is greater than bone conduction in the left ear. C. Sound is lateralizing to the right ear. D. Sound is lateralizing to the left ear.

A. Air conduction is less than bone conduction in the left ear.

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (Select all that apply.) A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine

A. Enlarged adenoids B. Report of recent colds

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (Select all that apply.) A. Reduce exposure to bright lighting B. Move head slowly when changing positions. C. Do not eat fruit high in potassium. D. Plan evenly-spaced daily fluid intake. E. Avoid fluids containing caffeine.

A. Reduce exposure to bright lighting B. Move head slowly when changing positions. D. Plan evenly-spaced daily fluid intake

A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

A. Ulceration

Which patient behaviors would the nurse promote for healthy eyes (select all that apply)? a. Protective sunglasses when bicycling b. Taking part in a smoking cessation program c. Supplementing diet intake of vitamin C and beta-carotene d. Washing hands thoroughly before putting in or taking out contact lenses e. A woman avoiding pregnancy for 4 weeks after receiving MMR immunization

ABCD

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply.) A. Sex B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

B, C, D, E

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? A. Basal cell carcinoma B. Melanoma C. Actinic keratosis D. Squamous cell carcinoma

B. Melanoma

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure

B. Opacity visible behind the pupil

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

B. Open-angle glaucoma

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

C & D

In a patient with vertigo, the parts of the ear most likely involved are the (select all that apply) a. cochlea. b. ossicles. c. vestibule. d. semicircular canals. e. tympanic membrane.

C, D

A nurse is preparing to administer timolol eye drops to a client who has primary open-angle glaucoma (POAG). Prior to administering the medication, the nurse should recognize that which of the following conditions in the client's medical history is a contraindication to receiving this medication? A. Hypertension B. Peripheral vision loss C. Asthma D. Increased intraocular pressure

C. Asthma

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? A. Cataracts B. Angle-closure glaucoma C. Retinal detachment D. Macular degeneration

C. Retinal detachment

A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A Partial-thickness burn B. Stage Ill pressure ulcer C. Surgical incision D. Dehisced sternal wound

C. Surgical incision

A nurse is assessing the abdominal incision of a client who is 3 days postoperative. The incision is slightly edematous and pink with crusting on the edges and is draining serosanguineous fluid. Which of the following assessments describes the incision? A. The incision is showing early signs of infection. B. The incision is showing early signs of dehiscence. C. The incision is showing signs of healing without complications. D. The incision is showing signs of developing a fistula.

C. The incision is showing signs of healing without complications.

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly. B. Instruct the client to look at the floor while instilling the eye drop. C. Remind the client to avoid using a facial tissue after instillation. D. Instruct the client to apply pressure to the inside corner of the eye after instillation.

D. Instruct the client to apply pressure to the inside corner of the eye after instillation.

Which of the following patients would be at greatest risk for basal cell carcinoma? A. Dark complexion, light eyes, underweight B. Light complexion, dark eyes, overweight C. Medium complexion, light eyes, smoker D. Light complexion, light eyes, fair hair

D. Light complexion, light eyes, fair hair

A nurse is planning care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? A. Curettage B. External radiation therapy C. Regional chemotherapy D. Surgical excision

D. Surgical excision

A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss

D. Unilateral hearing loss

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight erythema at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The patient has a normal inflammatory response. b. The abdominal incision shows signs of an infection. c. The abdominal incision shows signs of impending dehiscence. d. The patient's health care provider must be notified about her condition.

a. The patient has a normal inflammatory response.

Which safe sun practices would the nurse include in the teaching plan for a patient who has photosensitivity (select all that apply)? a. Wear protective clothing. b. Apply sunscreen liberally and often. c. Emphasize the short-term use of a tanning booth. d. Avoid exposure to the sun, especially during midday. e. Wear any sunscreen as long as it is bought at a drugstore.

a. Wear protective clothing. b. Apply sunscreen liberally and often. d. Avoid exposure to the sun, especially during midday.

Common age-related changes in the auditory system include (select all that apply) a. drier cerumen. b. tinnitus in both ears. c. auditory nerve degeneration. d. atrophy of the tympanic membrane. e. greater ability to hear high-pitched sounds.

a. drier cerumen. b. tinnitus in both ears. c. auditory nerve degeneration. d. atrophy of the tympanic membrane.

Care of the patient experiencing an acute attack of Ménière's disease includes (select all that apply) a. giving antiemetics as needed. b. implementing fall precautions. c. keeping the room dark and quiet. d. placing the patient on NPO status.

a. giving antiemetics as needed. b. implementing fall precautions. c. keeping the room dark and quiet.

Which patient has the greatest risk for experiencing delayed wound healing? a. A 65-yr-old woman with stress incontinence b. A 52-yr-old obese woman with type 2 diabetes c. A 78-yr-old man who has a history of hypertension d. A 30-yr-old man who drinks 2 alcoholic beverages per day

b. A 52-yr-old obese woman with type 2 diabetes

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? a. Subcutaneous b. Epidermis c. Dermis d. Stratum corneum

b. Epidermis

A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal body temperature? a. Using a cooling blanket while the patient is febrile b. Giving antipyretics on an around-the-clock schedule c. Providing increased fluids and have the UAP give sponge baths d. Giving prescribed antibiotics and placing warm blankets for comfort

b. Giving antipyretics on an around-the-clock schedule

The nurse determines that a patient with which disorder is most at risk for spreading the disease? a. Tinea pedis b. Impetigo on the face c. Candidiasis of the nails d. Psoriasis on the palms and soles

b. Impetigo on the face

Which strategies would best aid the nurse communicate with a patient who has a hearing loss (select all that apply)? a. Overenunciate speech. b. Speak normally and slowly. c. Exaggerate facial expressions. d. Raise the voice to a higher pitch. e. Write out names or difficult words.

b. Speak normally and slowly. e. Write out names or difficult words.

What assessment technique should the nurse use to assess an adult patient's tympanic membrane? a. Have the patient tilt the head toward the nurse. b. Stabilize the otoscope with your fingers on the patient's cheek. c. Pull the auricle down and back to straighten the auditory canal. d. Use a speculum slightly larger than the size of the patient's ear canal

b. Stabilize the otoscope with your fingers on the patient's cheek.

The nurse assessing a patient with a chronic leg wound finds local signs of erythema, and the patient reports pain at the wound site. What would the nurse expect to be ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

b. WBC count and differential

In a patient who has a hemorrhage in the posterior cavity of the eye, the nurse knows that blood is accumulating a. in the aqueous humor. b. between the lens and retina. c. between the cornea and lens. d. in the space between the iris and lens.

b. between the lens and retina.

The primary function of the skin is a. insulation. b. protection. c. sensation. d. absorption.

b. protection.

During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient's knees and elbows. You would describe this finding as a. lentigo. b. psoriasis. c. actinic keratosis. d. seborrheic keratosis.

b. psoriasis.

Presbyopia occurs in older people because a. the eyeball elongates. b. the lens becomes inflexible. c. the corneal curvature becomes irregular. d. light rays are focusing in front of the retina.

b. the lens becomes inflexible.

A patient says she was diagnosed with astigmatism. When she asks what that is, what is the best explanation the nurse can give to the patient? a. "It happens because the lens of the eye is absent." b. "People with astigmatism have abnormally long eyeballs." c. "The cornea of the eye is uneven or irregular with astigmatism." d. "Astigmatism occurs because the eye muscles weaken with age."

c. "The cornea of the eye is uneven or irregular with astigmatism."

Which order should a nurse question in the plan of care for an older adult, immobile stroke patient with a pink, clean stage 3 pressure injury? a. Pack the wound with foam dressing. b. Turn and position the patient every hour. c. Clean the wound every shift with Dakin's solution. d. Assess for pain and medicate before dressing change.

c. Clean the wound every shift with Dakin's solution.

Ask patients using eyedrops to treat their glaucoma about a. use of corrective lenses. b. their usual sleep pattern. c. a history of heart or lung disease. d. sensitivity to opioids or depressants.

c. a history of heart or lung disease.

A common site for the lesions associated with atopic dermatitis is the a. buttocks. b. temporal area. c. antecubital space. d. plantar surface of the feet.

c. antecubital space.

During the physical examination of a patient's skin, the nurse would a. use a flashlight in a poorly lit room. b. note cool, moist skin as a normal finding. c. pinch up a fold of skin to assess for turgor. d. perform a lesion-specific examination first and then a general inspection.

c. pinch up a fold of skin to assess for turgor.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision

c. severe eye pain

A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of malignant melanoma? a. Rough, dry, scaly skin b. Firm nodule with crusting c. pearly purple with ulcerated center d. Irregularly shaped lesion with blue tones

d. Irregularly shaped lesion with blue tones

When examining the patient's eyes, which finding would be of most concern to the nurse? a. Intraocular pressure of 16 mm/Hg b. Slightly yellowish cast of the sclera c. Outward turning of the lower lid margin d. Small, white nodule on the upper lid margin

d. Small, white nodule on the upper lid margin

Increased intraocular pressure may occur because of a. edema of the corneal stroma. b. dilation of the retinal arterioles. c. blockage of the lacrimal canals and ducts. d. increased aqueous humor production by the ciliary process.

d. increased aqueous humor production by the ciliary process.

A normal finding the nurse would expect when assessing hearing would be a. absent cone of light. b. bluish purple tympanic membrane. c. fluid level at hairline in the tympanum. d. midline tone heard equally in both ears.

d. midline tone heard equally in both ears.