SENSORY DISORDERS EXAM
A patient asks the nurse why the lights are being dimmed prior to the instillation of pupil-dilating eye drops. What is the best response by the nurse? 1 To decrease pain 2 To prevent anxiety 3 To minimize photophobia 4 To minimize intraocular pressure
3 To minimize photophobia Pupil dilation medications enlarge the pupil during eye examinations. After administering pupil dilation medications, patients generally have photophobia. Analgesics are administered to decrease pain. Anxiolytics are given to patients to prevent anxiety. Miotics and oral or intravenous hyperosmotic agents such as glycerin liquid, isosorbide solution, and mannitol solution are useful in lowering the intraocular pressure.
Two patients on your unit have recently returned to the postsurgical unit after knee arthroplasty. One patient is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other patient is reporting a pain level of 3 to 4 on the same pain scale. What is the nurses most plausible rationale for understanding the patients different perceptions of pain? A) Endorphin levels may vary between patients, affecting the perception of pain. B) One of the patients is exaggerating his or her sense of pain. C) The patients are likely experiencing a variance in vasoconstriction. D) One of the patients may be experiencing opioid tolerance.
A) Endorphin levels may vary between patients, affecting the perception of pain.
The home health nurse is developing a plan of care for a patient who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the patient teaching? A) Self-care and safety B) Autonomy and need C) Health promotion and exercise D) Dependence and health
A) Self-care and safety
Macular degeneration effects what age group?
Older Age
Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? A-Absence of pain or pressure B-Blurred vision in the morning C- Seeing colored halos around lights D-Eye pain accompanied with nausea and vomiting
A-Absence of pain or pressure Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma manifestations include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.
A health care provider writes the following order for an opioid naive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action: A. Calls the health care provider, and questions the order B. Applies the patch the third postoperative day C. Applies the patch as soon as the patient reports pain D. Places the patch as close to the hip dressing as possible
A. Calls the health care provider, and questions the order
A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? ( Select all that apply) A. I think I may be pregnant B. I take warfarin C. I take antihypertensive medications D. I'm allergic to shrimp E. I ate a light breakfast this morning
A. I think I may be pregnant B. I take warfarin D. I'm allergic to shrimp E. I ate a light breakfast this morning
A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse administer? A. Ketorolac B. Ketmine C. Meperdine D. Methadone
A. Ketorolac Rationale: It is in the NSAID category and useful for inflammation
A patient admitted with the diagnosis of possible myocardial infarction complains of pain and tingling in the left arm and says, "How in the world could I be having a heart attack when it's just my arm that is giving me trouble?" What type of pain should the nurse explain that the patient is experiencing? a. Referred pain b. Psychogenic pain c. Neuromuscular pain d. Muscle spasms of shoulder
ANS: A Pain is what the patient says it is and should be communicated as such. However, pain in specific areas may be referred pain, and left arm discomfort is typically referred from the heart. The nurse administers the analgesic as ordered and frequently checks to determine whether the pain is relieved.
What should greatly reduce postoperative pain for a patient about to undergo a hip replacement? a. Femoral nerve blocks b. Extremely deep general anesthesia c. Practicing leg lifting exercises before surgery d. Placing an analgesic patch directly over the incision
ANS: A Preoperative femoral nerve blocks will significantly reduce the pain for 24 hours postoperatively.
What sympathetic responses to pain might be assessed by the nurse? a. Increased blood pressure, increased pulse, and increased respiratory rate b. Decreased blood pressure, decreased pulse, and increased respiratory rate c. Increased blood pressure, decreased pulse, and increased respiratory rate d. Decreased blood pressure, decreased pulse, and decreased respiratory rate
ANS: A The sympathetic nervous system controls blood pressure, pulse, and respiration; it is stimulated during pain.
What intervention of pain control exemplifies the gate control methods of pain relief? a. Assisting the patient to ambulate b. Giving a massage c. Providing an ice cold beverage d. Instructing the patient in stretching exercises
ANS: B Massage, position change, hot or cold applications, and distraction all can close the gate.
When a patient with sciatica seats himself in a chair, he gasps and complains of a burning and shooting pain in his hip. What type of pain does this represent? a. Referred b. Neuropathic c. Visceral d. Acute
ANS: B Neuropathic pain is characterized by burning and shooting sensations without a stimulus. This situation is not an example of acute pain because neuropathic pain does not follow a nociceptor path as do both visceral and referred pain.
To perform a nursing assessment correctly, a nurse must remember that pain perception involves several central nervous system (CNS) processes. Which are examples of CNS processes? a. Afferent pathways carry messages to the spinal cord. b. Efferent pathways stimulate the spinal cord to recognize the location of pain. c. Nociceptors in the brain stimulate the spinal cord. d. Pain receptors in muscle, skin, and subcutaneous tissue stimulate efferent pathways.
ANS: B Pain perception ascends to the brain and back down again to imprint the pain. These are functions of the CNS. Efferent pathways carry pain impulses to the body via the spinal cord. Afferent pathways carry messages to the brain for interpretation.
What is the most common result of prolonged and unrelieved pain? a. Release of endorphins b. Lowered pain threshold c. Stimulated gate control d. Lowered blood pressure
ANS: B Pain that is unrelieved lowers the pain threshold because the patient becomes anxious that the pain may not ever be relieved. The blood pressure increases, and the effects of endorphins and gate control have been exhausted.
Every time the right arm is raised, a patient reports to the nurse that pain is triggered in the right shoulder. How should the nurse document this description? a. Referred pain b. Aggravating factor c. Alleviating factor d. Past experience with the pain
ANS: B The aggravating factor that is causing pain is important information to gather by the nurse and to communicate specifically in the chart, as well as to the registered nurse.
Which steps should the LPN/LVN follow when performing a pain assessment? a. Assess vital signs, status of pain, and aggravating factors. b. Assess location, quality, and intensity on an identified scale. c. Assess the intensity on an identified scale and record findings. d. Assess vital signs and location, and report to the RN.
ANS: B The assessment of pain requires the nurse assess location, quality, and intensity based on an identified scale. Vital signs are important in addition but are not part of the six steps.
A patient continues to report pain after the administration of the prescribed analgesic. Why should the nurse change the nursing care plan? a. Patient's pain threshold has risen. b. Patient's pain threshold has lowered. c. Patient has become addicted. d. Patient is seeking attention.
ANS: B The sensation of pain is perceived as increased when the pain threshold is lowered. Insufficient data exists in this situation to assume addiction or the need for attention.
A nurse is administering morphine IM, which was prescribed for a patient reporting severe pain. What should be the nurse's primary assessment focus on to evaluate the patient's response to this drug? a. Cardiac rhythms for tachycardia b. Respiratory rate for tachypnea c. Increased bowel sounds in the gastrointestinal system d. Sedative effects in the neurologic system
ANS: D Morphine initially produces sedation that allows the patient to sleep and rest from the pain. This result is considered a side effect.
What assessment should a nurse make to evaluate the presence of pain in a patient who is cognitively impaired? a. Amount of time spent sleeping during the day b. Consistent stoic facial expression c. Increased social interaction d. Increasing confusion
ANS: D Patients who are cognitively impaired may show pain by increased confusion, reduction in social contacts, grimacing, or squinting the eyes.
A patient with an extensive abdominal surgical procedure is assessed by the nurse as having predictable pain. How often should the nurse administer analgesics to this patient to be most effective? a. As needed (PRN) b. Once a day c. Twice a day d. Around the clock
ANS: D Using a preventive approach for managing this patient's pain management is the best plan for the nurse because the pain is predictable and major.
In reviewing a 50-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess? a.visual acuity. b.pupil reaction. c.color perception. d.peripheral vision
ANS: D Peripheral Vision The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.
A student nurse is assisting a patient who is blind using a sighted-guide technique. Which action by the student nurse requires immediate intervention? 1 Walking behind the patient holding the patient's back 2 Describing the environment to the patient while walking 3 Helping the patient to sit by placing the patient's hand on the seat of the chair 4 Standing slightly in front and to one side of the patient and providing elbow for support
ANSWER 1 While assisting a blind patient using sighted-guide technique, the nurse should walk slightly ahead of the patient, with the patient holding the back of the nurse's arm. This action will help the blind patient to walk easily. The nurse should describe the environment while walking to help orient the patient. The student nurse should help the patient sit by placing one of his or her hands on the seat of the chair. The nurse should stand slightly in front and to one side of the patient and provide an elbow for the patient to hold.
The nurse should assess an older adult withmacular degeneration for:■ 1. Loss of central vision.■ 2. Loss of peripheral vision.■ 3. Total blindness.■ 4. Blurring of vision.
ANSWER 1 Loss of central vision Macular degeneration generally involvesloss of central vision. Gradual blurring of vision canoccur as the disease progresses and may result inblindness; however, loss of central vision is the mostcommon fi nding. Tiny yellowish spots, known asdrusen, develop beneath the retina. Loss of peripheralvision is characteristic of glaucoma.
On a home visit to a patient who underwent cataract surgery, the nurse finds that the patient has intense pain in the operated eye. What should be the immediate nursing action? 1 Notify the surgeon. 2 Administer analgesics. 3 Apply a cold compress. 4 Administer eyedrops.
ANSWER 1 Notify the Surgeon In the postoperative period after a cataract surgery, the pain is usually mild. However, if the patient complains of intense pain, it should be immediately communicated to the surgeon, because it may indicate hemorrhage, infection, or increased intraocular pressure, and thus may need prompt intervention. Analgesics can be administered after receiving a surgeon's prescription. Applying a cold compress or administering eye drops may not decrease the pain.
A client sustains a contusion of the eyeball following a traumatic injury with a blunt object.The nurse takes which action immediately? 1. Notifies the physician 2. Irrigates the eye with cool water 3. Applies ice to the affected eye 4. Accompanies the client to the emergency room
ANSWER 3. Applies ice to the affected eye Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately.The client should receive a thorough eye examination to rule out the presence of other eye injuries. Eye irrigation is not indicated in a contusion. Options 1 and 4 will delay immediate treatment. Following the application of ice, the physician would be notified.
During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: A Call the physician B Administer the ordered main medication and antiemetic C Reassure the client that this is normal. D Turn the client on his or her operative side
ANSWER A Call the Physician Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate.
Priority Decision: What nursing action is most important for the patient with age-related macular degeneration(AMD)? a. Teach the patient how to use topical eyedrops for treatment of AMD. b. Emphasize the use of vision enhancement techniques to improve what vision is present. c. Encourage the patient to undergo laser treatment to slow the deposit of extracellular debris. d. Explain that nothing can be done to save the patient's vision because there is no treatment for AMD.
ANSWER B Emphasize the use of vision enhancement techniques to improve what vision is present. The patient with AMD can benefit from low-visionaids despite increasing loss of vision and it is importantto promote a positive outlook by not giving patientsthe impression that "nothing can be done" for them.Laser treatment may help a few patients with choroidalneovascularization and photodynamic therapy is indicatedfor a small percentage of patients with wet AMD but thereis no treatment for the increasing deposit of extracellulardebris in the retina.
The nurse is assessing a client with macular degeneration. Identify the illustration that best depicts what clients with this disorder typically see. A. See everything clear B. Outer vision is blackened out, but center field is clear c. Center field is blackened out and outer field is clear D. Everything is blurry
ANSWER C: In macular degeneration the center vision is blackened out and only the outer visual fields are clear.
A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the client? a) the sutures are removed after 1 week b) wound healing usually takes 12 weeks c) expect that vision will be permanently impaired d) a shield or eye patch should be worn to protect the eye
ANSWER D a shield or eye patch should be worn to protect the eye After ocular surgery, the client should wear an eye patch or eyeglasses for the protection of the eye. Healing takes place in about 6 weeks. When the postoperative inflammation subsides, the client's vision should return to the preoperative level of acuity. Sutures are usually absorbable.
After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic examination, which of the following instructions would be given to the client? A "Be careful because the blink reflex is paralyzed." B "Avoid wearing your regular glasses when driving." C "Be aware that the pupils may be unusually small." D "Wear dark glasses in bright light because the pupils are dilated."
ANSWER D "Wear dark glasses in bright light because the pupils are dilated." Atropine, an anticholinergic drug, has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn't paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision.
Increased intraocular pressure may occur as a result of a. edema of the corneal stroma. b. dilation of the retinal arterioles. c. blockage of the lacrimal canals and ducts. d. increased production of aqueous humor by the ciliary process.
ANSWER D increased production of aqueous humor by the ciliary process.
A patient, discharged after eye surgery, is told to avoid activities that will increase intraocular pressure. Which activities should the patient avoid? Select all that apply. 1 Eating 2 Lifting 3 Coughing 4 Bending over 5 Breathing deeply
ANSWER: 2, 3, 4. Activities such as coughing, bending over, and lifting, increase the pressure within the eye. Eating and breathing deeply do not involve straining or lowering the head, so the pressure within the eye is not increased.
The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? A Self-care deficit B Imbalanced nutrition C Disturbed sensory perception D Anxiety
ANSWER: C Disturbed Sensory Preception The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Disturbed sensory perception (visual) related to lens extraction and replacement. Although the other options identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery.
In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled? A An osmotic diuretic B A miotic agent C A mydriatic medication D A thiazide diuretic
ANSWER: C Mydriatic Medication A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medication act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract.
When assessing a client, the nurse notes absence of the red reflex in the client's right eye. On questioning, the client responds, "Oh yes, my doctor told me I have cataracts. When should I have them removed?" How should the nurse respond? a "Are you starting to experience frequent headaches or pain in your right eye?" b "Cataracts can be removed any time that it is convenient for you." c "It appears that the right eye is due for surgery." d "Are you having difficulty reading or doing activities you enjoy?"
ANSWER: D "Are you having difficulty reading or doing activities you enjoy?"
Which of the following instruments is used to record intraocular pressure? A Goniometer B Ophthalmoscope C Slit lamp D Tonometer
ANSWER: D Tonometer A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.
Which precaution is most important for the nurse to teach a 62-year-old client newly diagnosed with early-stage dry age-related macular degeneration? A. Quit smoking B. Quit drinking alcoholic beverages C. Eat more dark green, red, and yellow vegetables D. Wear dark glasses whenever he or she is outside or in bright interior lighting environments
Answer: A Rationale: Dry AMD is more common and progresses at a faster rate among smokers than among nonsmokers. Thus, quitting smoking can slow the rate of AMD progression. Avoiding alcohol and bright light (even ultraviolet light) is not related to AMD development or progression. Although increasing long-term dietary intake of antioxidants, vitamin B12, and the carotenoids lutein and zeaxanthin that are found in green, red, and yellow vegetables is thought to help slow the progression of AMD, the effects are not as profound as quitting smoking.
The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds
Answer: A, D, E Rationale: Any action that would increase pressure in the eye should be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects. Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.
What is the action of miotics in the client with glaucoma? A. Decrease the inflammatory process B. Enhance aqueous outflow C. Increase the production of vitreous humor D. Vasoconstrict the blood vessels in the eye
Answer: B Rationale: Miotics are used to improve the flow of fluid (aqueous humor) and decrease intraocular pressure in clients with glaucoma. Steroid drops, not miotics, decrease the inflammatory process. Vitreous humor fills the space between the lens and the retina, is stagnant, and is not replenished as the aqueous humor is. Miotics make the pupil smaller, which creates more room between the iris and the lens.
The nurse is teaching a client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? A. "I must wait 10 to 15 minutes between different eyedrop medications." B. "I must press on the inside of my eye to prevent washout." C. "It is important to not skip a dose." D. "These eyedrops will not cure my glaucoma."
Answer: B Rationale: Pressing on the inside of the eye after instillation of eye medication prevents systemic absorption of the drug. To avoid washout, the client should wait 10 to 15 minutes between eyedrop medications. Skipping a dose will not exacerbate the client's glaucoma. Medication will not cure glaucoma, but it will control its progression.
The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply.) A. "You will need to wear a patch on your eye for several weeks after the surgery." B. "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." C. "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." D. "Bring sunglasses with you on the day of your procedure."E. "You might experience a lot of bruising and swelling around the eye."
Answer: B, C, D Rationale: The client will have multiple eyedrops to use after surgery and should be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eyedrops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure. A patch is required after surgery only if a risk for injury is present. Cataract surgery does not cause bruising and swelling post-surgery.
A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? A. Increased tearing B. Itching of the eye C. Reduction in vision D. Swollen eyelid
Answer: C Rationale: A reduction in vision after cataract surgery indicates a problem, and the client should notify the provider immediately. Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.
During patient teaching regarding self-administration of ophthalmic drops, with statement by the nurse is correct? A. "Hold the eyedrops over the cornea, and squeeze out the drop." B. "Apply pressure to the lacrimal duct area for 5 minutes after administration." C. "Be sure to place the drop in the conjuctival sac of the lower lid." D. "Squeeze your eyelid closed tightly after placing the drop into your eye."
Answer: C Rationale: Because the cornea is sensitive, most eye medications are placed inside the lower lid. For systemic osmotic drugs, pressure only needs to be applied to lacrimal duct for 60 seconds.
Which assessment is most important for the nurse to perform before instilling travoprost (Travatan) into the client's eye? A. Measuring the client's blood pressure B. Measuring the client's intraocular pressure C. Checking the cornea for abrasions or open areas D. Assessing heart rate and rhythm for 1 full minute
Answer: C Rationale: Travoprost is a prostaglandins agonist. Drugs from this class should not be applied unless the cornea is completely intact. Measuring intraocular pressure is not necessary when a diagnosis of glaucoma has been established. Prostaglandins agonists, even if systemically absorbed, do not affect body blood pressure or heart rate and rhythm.
The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: A Eye pain B Floating spots C Blurred vision D Diplopia
Answer: C Blurred Vision A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.
A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? A. Burning in the eye B. Inability to differentiate colors C. Increased sensitivity to light D. Gradual vision changes
Answer: D Rationale: Gradual vision changes are an indication of increased intraocular pressure. A burning sensation in the eye usually indicates inflammation and/or infection. An inability to differentiate colors is an early sign of cataracts. An increased sensitivity to light might be a sign of a corneal abrasion.
The client who had cataract surgery with a lens implant 1 week ago remarks to the home care nurse that after his daughter left to go to her home in another state yesterday, he combined all of his prescribed eyedrops together in one container so he had fewer drops to administer. What is the nurse's best response? A. "This is not a good idea because not all of the drugs are on the same schedule." B. "That is a good idea; just remember to not touch the dropper to your eye when giving yourself the drops." C. "Call your surgeon immediately and get new prescriptions because together these drugs can lower your blood pressure." D. "Call your surgeon immediately and get new prescriptions to use one at a time because these drugs cannot be mixed together."
Answer: D Rationale: These drugs are not to be mixed together. Not only is the chance for contamination high, but the drug concentrations and effectiveness are also reduced when mixed together. Even when the drugs are administered separately, they should be given 5 to 10 minutes apart.
The nurse is assessing a patients pain while the patient awaits a cholecystectomy. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates his pain as a 2 at this time using a 0-to-10 pain scale. How should the nurse best respond to this assessment finding? A) Remind the patient that he is indeed experiencing pain. B) Reinforce teaching about the pain scale number system. C) Reassess the patients pain in 30 minutes. D) Administer an analgesic and then reassess.
B) Reinforce teaching about the pain scale number system.
A nurse performs an assessment of a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which of the following symptoms? a) loss of peripheral vision b) blurred central vision c) increased clarity when looking at objects d) clear vision when reading
B- The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients might complain of visual distortion, usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk.
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D."You will need to lie flat for 4 hours after the procedure."
B. "Try to stay awake most of the night prior to the procedure."
A nurse is caring for a client post-procedure following lumbar puncture and reports a throbbing headache when sitting up. Which of the following actions should the nurse take? (Select all that apply) A. Use Glasgow Come Scale B. Administer opioid medication C. Encourage the client to increase fluid intake D. Assist into supine position E. Instruct the client to perform deep breathing and coughing exercises
B. Administer opioid medication C. Encourage the client to increase fluid intake D. Assist into supine position
1. A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) A. Use the Glasgow Coma Scale when assessing the client. B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake. E. Instruct the client to perform deep breathing and coughing exercises.
B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake.
A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 =11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8
B. E3 + V4 + M4 = 11
A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? A. Stool softener B. Stimulant laxative C. H 2 receptor blocker D. Proton pump inhibitor
B. Stimulant laxative
The nurse is caring for a 51-year-old female patient whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of what consequent health problem? A) Anxiety B) Skin breakdown C) Depression D) Hallucinations
C) Depression
A nurse at a clinic is talking with a client who has cancer and take extended-release opioids BID. The client reports an increase in localized, achy pain over the last few days. how should the nurse document this increase? A. Phantom Limb Pain B. Mixed Pain C. Breakthrough Pain D. Neuropathic Pain
C. Breakthrough Pain Rationale: Breakthrough pain is beyond the level the patient is used to having.
A nurse caring for a client who is receiving morphine via a PCA infusion device after an abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? A. I'll wait to use this device until it is absolutely necessary B. I'll be careful about pushing the button so I dont overdose C. I should tell the nurse if the pain doesn't stop after I use this device D. I will ask my son to push the dose button when I am sleeping
C. I should tell the nurse if the pain doesn't stop after I use this device
The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? A. The patient's level of pain B. The potential for addiction C. The amount of daily acetaminophen D. The risk for gastrointestinal bleeding
C. The amount of daily acetaminophen
What are some risk factors for cataracts?
1. Advanced age 2. Diabetes 3. Hereditary 4. Smoking 5. Eye Trauma 6. Excessive Exposure to the Sunlight 7. Chronic use of: - corticosteroids - Phenothiazine - Beta Blockers - Miotic Medications
Risk factors of glaucoma?
1. Age (Over 40) 2. Infection 3. Tumors 4. Diabetes 5. Genetic Disposition 6. Hypertension 7. Eye trauma 8. Severe Myopia 9. Retinal Detachment
What are common causes of cataracts?
1. Age = Drying of lens due to water loss 2. Traumatic = Blunt or penetrating injury to the eye 3. Toxic = Long term use of corticosteroids 4. Associated = Diabetes Mellitus, Hypoparathyroidism, Down Syndrome, Chronic sunlight exposure 5. Complicated = Intraocular Disease like glacoma, retinal detachment and retinitis pigmentosa
What are some expected findings of cataracts?
1. Decreased Visual Acuity 2. Blurred Vision 3. Diplopia (Double Vision) 4. Progressive and Painless Loss of Vision 5. Visible Opacity 6. Absent Red Reflex (may also clue you in to other pathologies in the cornea (abrasion, infection, or scar), vitreous (hemorrhage or inflammation), or retina (retinal detachment)
What should the nurse plan for when caring for a patient with dry macular degeneration?
1. Encourage foods high in antioxidants, carotene, E and B12 2. Refer client to organizations who assist in transportation since driving will be an issue
The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply 1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheek bone. 5. Instruct the client to squeeze the eyes shut after instilling the eyedrop. 6. Instruct the client to tilt the head forward, open the eyes, and look down.
1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheek bone.
What are some health and disease promotion?
1. Wear sunglasses when outside 2. Protective eye wear when playing sports or performing hazardous activites 3. Annual eye exams
What is the expected range for Intraocular Pressure (IOP)?
10 - 21 mm/Hg
Which statement made by a client to the nurse indicates an understanding of home care instructions after cataract surgery? a. I should not bend over to pick up objects from the floor b. I can sleep on whichever side I want as long as my head is raised c. I may not watch TV for 6 weeks d. I should keep the protective eye shield in place 24 hours a day
a. I should not bend over to pick up objects from the floor
A nurse is assessing a client following cataract surgery. The client reports nausea and severe eye pain. Which of the following actions should the nurse take? a. notify the provider b. administer an analgesic c. administer an antiemetic d. turn the client onto the operative side
a. notify the provider medications should not be administered until evaluated by the provider turning the client on the operative side could result in increased eye pain and worsen the nausea.
The nurse is caring for a client who is in the recovery area following cataract surgery. The nurse would ask the client about which manifestations that would indicate onset of retinal detachment as a postoperative complication? select all that apply: a. increased lacrimation b. flashing lights c. sudden, severe eye pain d. inability to move the eye e. loss of part of visual field in the eye
b. flashing lights e. loss of part of visual field
After a client has undergone outpatient surgery for a right eye cataract removal, the nurse teaches the client to avoid which activity when the client gets home? select all That Apply a. walking about the house unassisted b. lying on the right side c. picking up the objects that are at waist level d. washing dishes in the sink e. mowing the lawn
b. laying on the right side e. mowing the lawn
When a client who has undergone cataract extraction is preparing to go home, the nurse reinforces which of the following instructions? a. Remove the dressing at bedtime. b. Set a new appointment with the surgeon for 1 month from the day of discharge. c. Avoid sleeping on the operative side. d. Expect a headache for the first few days after the procedure.
c. avoid sleeping on the operative side
A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following clinical manifestations should the nurse expect to find? select all a. eye pain b. floating spots c. blurred vision d. white pupils e. bilateral red reflexes
c. blurred vision d. white pupilsfloating spots = retinal detachment e. red reflexes are ABSENT
- IOP rises Suddenly - Angle between the iris and the sclera suddenly closes - Requires immediate treatment What am I Primary Open or Primary Angle Glaucoma?
Primary Angle Glaucoma
-Most common form of glaucoma - Angle between the iris and scelra - Aqueous humor outflow is decreased due to blockages in the eyes drainage system - gradual rise in IOP Which am I Primary Open or Primary Angle Glaucoma
Primary Open Glaucoma
This can result from trauma to the eye, surgery, tumors, uveitis, iritis, neovascular disorders, degenerative disease, or central retinal vein occlusion?
Secondary Glaucoma
True or False: There is no cure for macular degeneration?
TRUE
What part of the eye does macular degeneration effect?
The Macula
The 65-year-old client is diagnosed with macular degeneration. Which statement by thenurse indicates the client needs more discharge teaching? 1. "I should use magnification devices as much as possible." 2. "I will look at my Amsler grid at least twice a week." 3. "I am going to use low-watt light bulbs in my house." 4. "I am going to contact a low-vision center to evaluate my home."
#3 3. "I am going to use low-watt light bulbs in my house."
The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this patient? A) Medication should be taken when pain levels are low so the pain is easier to reduce. B) Pain medication can be increased when the pain becomes intense. C) It is difficult to control chronic pain, so this is an inevitable part of the disease process. D) The patient will likely benefit more from distraction than pharmacologic interventions.
A) Medication should be taken when pain levels are low so the pain is easier to reduce.
What are the risk factors for macular degeneration?
1. Smoking 2. Hypertension 3. Being Female 4. Short Body Stature 5. Lack of Carotene and Vit-E
On a client's return from cataract surgery, the nurse in the ambulatory surgery recovery unit places the client: a On the affected side. b In a private room. c In semi-Fowler's position. d Near the nurse's station.
ANSWER : C Semi-Fowlers decrease intraocular pressure
Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client's chart and understands that normal intraocular pressure is: A 2-7 mmHg B 10-21 mmHg C 22-30 mmHg D 31-35 mmHg
ANSWER B 10 -21 mm/Hg Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mmHg are considered within normal range.
You are the emergency department (ED) nurse caring for an adult patient who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain are you addressing when you provide care for this patient? A) Chronic B) Acute C) Intermittent D) Osteopenic
B) Acute
Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patients orders specify an initial bolus dose. What is your priority assessment? A) Assessment for decreased level of consciousness (LOC) B) Assessment for respiratory depression C) Assessment for fluid overload D) Assessment for paradoxical increase in pain
B) Assessment for respiratory depression
Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95% B. Difficulty arousing the patient C. Respiratory rate of 10 breaths/min D. Pain intensity rating of 5 on a scale of 0 to 10
B. Difficulty arousing the patient
Your patient is 12-hours post ORIF right ankle. The patient is asking for a breakthrough dose of analgesia. The pain-medication orders are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? A) To prevent respiratory depression from the opioid B) To eliminate the need for additional medication during the night C) To achieve better pain control than with one medication alone D) To eliminate the potentially adverse effects of the opioid
C) To achieve better pain control than with one medication alone
The nurse is preparing to administer timolol eye drops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? A-"I have sinusitis." B-"I have migraine headaches a lot." C-"I have chronic obstructive pulmonary disease." D-"I have a history of chronic urinary tract infections."
C-"I have chronic obstructive pulmonary disease." Timolol is a nonselective β-adrenergic blocker that could lead to bronchoconstriction and bronchospasm. For this reason, it should not be used in patients with COPD. Timolol may be used to treat migraine headaches, and it does not affect sinusitis or chronic urinary tract infections.
A nurse monitoring a client who is receiving opioid analgesics. Which of the following findings should the nurse identify as adverse effects of the opioids analgesics? (Select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orhtostatic Hypotension E. Nausea
C. Bradypnea D. Orhtostatic Hypotension E. Nausea
This is an opacity in the lens of the eye that impairs vision?
Cataract
When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? A- Inner canthus B- Outer canthus C- Center of the eyeball D- Lower conjunctival sac
D- Lower conjunctival sac Ocular medications such as pilocarpine should be instilled into the lower conjunctival sac. Never apply eye drops directly to the cornea. Applying the drops to the inner canthus will cause them to be distributed systemically.
The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? A-Decrease fluid intake to control the intraocular pressure B-Avoid overuse of the eyes C-Decrease the amount of salt in the diet D-Eye medications will need to be administered lifelong.
D-Eye medications will need to be administered lifelong.
A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? A. Most clients exaggerate their level of pain B. Pain must have an identifiable source to justify the use of opioids C. Objective data are essential in assessing pain D. Pain is whatever the client says it is
D. Pain is whatever the client says it is
A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Addiction. B. Tolerance. C. Pseudoaddiction. D. Physical dependence.
D. Physical dependence.
This macular degeneration is: -Most common -Gradual blockage in retinal capillary arteries - Lack of nerves cells that results in ischemic or necrotic symptoms
DRY
What are the 2 types of macular degeneration?
Dry & Wet
This disorder is a disturbance of the functional or structural integrity of the optic nerve?
Glaucoma
This is the disorder of central loss of vision?
Macular Degeneration
2. A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension
B. Infection
A nurse is caring for a client who experienced a traumatic head injury and has intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension
B: Infection
