Week 8 (Ch 7, 8, 19, 20)
A client diagnosed with posttraumatic stress disorder (PTSD) tells the nurse about having "flashbacks" during waking hours or nightmares in which the past traumatic event is relived, often in vivid and frightening detail. What term for this experience will the nurse document in the client's record?
Intrusion
The nurse has just received the laboratory results of a client's calcium level. The nurse identifies a normal calcium level as:
8.5 to 10.5 mg/dl (2.25 mmol/l to 2.6 mmol/l)
A nurse is providing care for several clients on an acute medicine unit. Which client should the nurse recognize as being at the highest risk for metabolic alkalosis?
A client on continuous nasogastric suction and whose hypertension is being treated with diuretics
Of the following clients, who would be at highest risk for developing hyperkalemia?
A male admitted for acute renal failure following a drug overdose
The client is hospitalized for 4 days with an acute myocardial infarction. After a coronary artery stent is placed, the client is discharged to home in stable condition. This would be an example of which pattern of stress?
Acute time limited
A client's most recent laboratory results suggest the presence of metabolic alkalosis. What action by the nurse best addresses a potential cause of this acid-base imbalance?
Administering an antiemetic to treat the client's frequent vomiting
As a nurse prepares to change a client's dressing, the client states that she is afraid that it will be painful. Noting that the client's heart rate and respiratory rate have increased, the nurse adjusts the plan of care to reflect care for a client in which phase of Selye's general adaptation syndrome?
Alarm
What is ocular muscle imbalance resulting in "lazy eye" called?
Amblyopia
A health care provider suspects a client has developed posttraumatic stress disorder (PTSD). Select the necessary criterion to validate the diagnosis.
At least 1 month of clinically significant distress affecting a person after witnessing or experiencing a traumatic event that affects other parts of his or her life
The nurse is working at a first aid station in an amusement park. A 45-year-old client arrives reporting severe dizziness after a ride on the roller coaster. The nurse understands that a common cause of this sensation is:
Benign paroxysmal positional vertigo
A 26-year-old client who has recently traveled by airplane complains of pain in his right ear. The nurse suspects which condition?
Barotrauma
A young child has been diagnosed with amblyopia. The parents ask the nurse when treatment should be considered. At what age should treatment of children with the potential for development of amblyopia be instituted?
Before 6 years
The client has expressed a desire to explore stress-reducing strategies for chronic migraines. The provider explains one technique that involves electronic monitoring of physiologic responses to stress with immediate feedback. This is known as which of the following?
Biofeedback
What is the uveal tract composed of? Select all that apply.
Choroid Ciliary body Iris
A client has been diagnosed with bilateral cataracts associated with having difficulty seeing clearly. Reviewing the medication history, which drug may be responsible for the development of this condition?
Corticosteroids
The nurse is caring for a client who has been diagnosed with presbycusis. The nurse understands that with this disorder, the client experiences which of the following?
Difficulty hearing high-pitched frequencies
Most physiologic control systems function under positive feedback mechanisms.
False
Vitreous humor occupies the posterior portion of the eyeball. It is an amorphous biologic gel. When liquefaction of the gel occurs, as in aging, what can be seen during head movement?
Floaters
Two people experience the same stressor, yet only one is able to cope and adapt adequately. Which term do physiologists use to describe this effect, which is correlated to positive health outcomes?
Hardiness
A nurse is caring for a client with hypoparathyroidism. Which imbalance is a major concern for the client?
Hypocalcemia
A nurse is caring for an adolescent with posttraumatic stress syndrome. The client reports having difficulty concentrating and has an increased startle reflex. The nurse's documentation includes the presence of:
Hyperarousal
Respiratory alkalosis can be caused by a respiratory rate in excess of that which maintains normal plasma PCO2 levels. What is a common cause of respiratory alkalosis?
Hyperventilation
What will the nurse assess as the end result of activation of the renin-angiotensin-aldosterone system?
Increased blood pressure
Which intervention is a priority for the nurse when caring for a client with hypokalemia?
Initiating cardiac monitoring
During an eye assessment the nurse notes inflammation of the client's cornea. The nurse should document this as which condition?
Keratitis
Amblyopia, or lazy eye, occurs at a time when visual deprivation or abnormal binocular interactions occur in visual infancy. Whether amblyopia is reversible depends on which factor?
Maturity of the visual system at time of onset.
A client tells the nurse that the client has been taking Alka-Seltzer (bicarbonate—antacid) four times a day for the past 2 weeks for an upset stomach. Upon assessment of the client, the nurse notes hyperactive reflexes, tetany, and mental confusion. Arterial blood gases reveal pH 7.55; serum HCO3− 37 mEq/L (37 mmol/L). The nurse suspects the client may be experiencing:
Metabolic alkalosis
The manifestations of the stress response are strongly influenced by which system?
Nervous
A client has glaucoma. The nurse is taking a health history and knows that the most common form of glaucoma is which type?
Open angle
Water movement from the side of the membrane having a lesser number of particles and greater concentration of water to the side having a greater number of particles and lesser concentration of water is termed:
Osmosis
With aging, progressive inelasticity and thickening of the lens causes which accommodation disorder?
Presbyopia
An older adult client comes to the clinic complaining of seeing flashing lights and small spots. The client tells the nurse that this has been going on for over 24 hours but now it is as if there is a dark curtain whenever the client opens the eyes. The client asks the nurse if this means that blindness is imminent. What diagnosis should the nurse suspect?
Retinal detachment
A client expresses concern about feeling fullness in the ear. Which additional manifestation leads the health care provider to suspect Menière disease?
Rotary vertigo and tinnitus
The nurse is caring for an older adult client with a suspected diagnosis of presbycusis. Select the most likely manifestation.
Sensorineural hearing loss caused by natural aging
A young child is flying on a plane for the first time. As the plane begins its descent for landing, the child's ears begin to hurt. The flight attendant sees that the child is in pain and tells the child to swallow until the pain goes away. Which structure is the child using to equalize the pressure and relieve the pain?
Swallowing pulls air through the Eustachian tubes, allowing the air pressure to equalize in the inner ear.
The parents of a 6-month-old child who was born with a blocked tear duct are concerned because their child has been waking up the past few mornings with inflammation in the left eye and yellow, dried secretions preventing eye opening in spite of massaging the tear duct. The nurse would anticipate which of the following?
The child has developed dacryocystitis.
A client's chart documents the finding of cholesteatoma. The nurse interprets this to mean that the client has:
cystlike mass in the middle ear.
The nurse understands that movement of otoliths may result in:
vertigo and nystagmus.
A client with a diagnosis of benign paroxysmal positional vertigo (BPPV) is receiving teaching from her physician about her diagnosis. The client is eager to avoid future episodes of vertigo and has asked the physician what she can do to prevent future episodes. How can the physician best respond?
"There are some exercises that I'll teach you to help reorient your inner ear and prevent vertigo."
The fight-or-flight response is a manifestation of the stress reaction caused by which part of the nervous system?
Sympathetic