6270 Exam #2 11

Buerger's disease is characterized by all of the following except: AArterial thrombosis formation and occlusion BLipid deposits in the arteries CRedness or cyanosis in the limb when it is dependent DVenous inflammation and occlusion

BLipid deposits in the arteries

Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.

3. Memory deficits are cognitiveimpairments. The client may alsodevelop a dementia.

A patient taking aspirin for stroke prevention reports the development of hearing disturbances. The appropriate intervention is to decrease the dose in order to prevent which following conditions? A. Ototoxicity B. Vertigo C. Nystagmus D. Otitis externa

A Ototoxicity

Peptic ulcer risk

Age 40-60, after menopause, infection with H. pylori, excessive HCL secretion, stress/anxiety, family tendency, type O blood, chronic pulmonary/kidney disease, NSAIDs, alcohol, smoking

Otitis media risk factors

Age, anatomy, family hx, immune system development

Stroke risk factors (non-modifiable)

Age, family hx, previous stroke/TIA, race (African American, Hispanic, Asian, Native American), men

Transmission of HIV

1. Any affected person can transmit 2. Blood, semen, vaginal/cervical fluids

Low vision is defined as a best corrected visual acuity (BCVA) of

20/70 to 20/200.

Which term refers to the progressive hearing loss associated with aging? A) Otalgia B) Presbycusis C) Exostoses D) Sensorineural hearing loss

B) Presbycusis

Acoustic neuroma nursing treatments

Fall risk (balance), risk for imbalanced nutrition (weak facial muscles), disturbed sensory perception (auditory)

Transgender inclusivity in healthcare

Gender-neutral terms, preferred name/pronouns

Meningitis manifestations

Headache, fever, nuchal rigidity, + Kernig & Brudzinski sign, photophobia

Consequences of kidney stones

Hemorrhage, infection, retained stone fragments, obstruction

A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the patient's expected response to this medication, what is most important for the nurse to assess? Improved skin turgor Decreased cardiac rate Improved finger perfusion Decreased mean arterial pressure

Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved and vasospastic attacks reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status.

Constipation interventions/education

Increase fiber/fluids, routine exercise, treat underlying cause, reduce anxiety, bowel training/goals

CKD abnormal labs

Increased protein in urine, decreased GFR

Macular degeneration vision impact

Lines appear shaded or distorted

Seizure nursing priorities

Maintain airway (ABCs), protect patient, accurate/descriptive documentation, medication administration, monitor vitals before/during/after

Characteristics of embolic stroke

Onset unrelated to activity, quick onset and resolution, associated with endocardial disorders

HIV Antiretroviral therapy patient education/RN diagnosis

Patient adherence is #1 priority (drug resistance)

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.

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.

Nursing implications for unilateral neglect

Rehabilitation, encourage use of neglected side, skin integrity

Cataract vision impact

Results in primarily painless, blurry vision

Characteristics of intracerebral hemorrhage

Rupture of atherosclerotic vessels, carries the poorest prognosis, creates mass that compresses the brain

Subarachnoid hemorrhage causes:

Rupture of cerebral aneurysm due to head trauma Elderly: falls Young: MVA

Vulvovaginal infection risks

STIs, poor hygiene, multiple sex partners, douching

Varicose veins can cause changes in what component of Virchow's triad? A Blood coagulability B Vessel walls C Blood flow D Blood viscosity

C Blood flow

Which of the following characteristics is typical of the pain associated with DVT? A Dull ache B No pain C Sudden onset D Tingling

C Sudden onset DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause pain.

Meningiomas

CNS

Oncologic Emergencies: Sepsis/septic shock

Can result in MODS

What eye condition is associated with painless and blurry vision at any age? SATA Glaucoma Presbyopia Cataracts Stygmatism

Cataracts Stygmatism

End-stage renal disease

Cccurs when chronic kidney disease — the gradual loss of kidney function — reaches an advanced state. In end-stage renal disease, your kidneys are no longer able to work as they should to meet your body's needs

Fibromyalgia s/sx

Chronic widespread pain, sleep disturbances, fatigue, morning stiffness, muscle weakness/paresthesia, cognitive dysfunction, chronic headaches, mood disturbances, IBS

Parkinson's disease nursing priorities

Controlling symptoms, maintaining functional independence, enchanting mobility, improving nutrition/communication, supporting coping ability, maintain safety

DVT lab monitoring

D-dimer blood assay

Transgender health outcomes

Due to lack of access to care, tend to have worse outcomes

Leukemia

blood/marrow

Halos around the eyes are associated with

glaucoma

rapid rise in intraocular pressure symptoms and damage are obvious requiring immedicate attention

glaucoma - closed angle

caused by slow blockage of the drainage canals increased introcular pressure fluid accumulation causes wide space between iris and cornea develops slowly and is life long condition symptoms and damage are not obvious

glaucoma - wide angle

Rheumatoid arthritis and osteoarthritis differences

- Osteoarthritis (OA) occurs over a course of many years, where RA is rapid within weeks to months -OA often beings unilaterally, and is limited to one set of joints, where RA is symmetrical and affects small and large joints -OA worsens with use of joint, and RA may improve with usage of joint -OA has no systemic symptoms, RA does

4 major causes of hemorrhagic stroke

1)deep hypertensive intracerebral hemorrhages, 2)ruptured saccular aneurysms, 3)arteriovenous malformation,4)spontaneous lobar hemorrhages

Ostomy stoma assessment

1. Assess ape, protrusion, size 2. Assess mucocutaneous. junction 3. Assess skin - should be intact and without signs of irritation/erosion

UTI causes

1. E. coli or C. albicans 2. Anatomical factors, compromised immune system, urinary stasis, foreign instrumentation, functional disorders, poor hygiene

Transplant recipient/donor selection criteria

1. Exclusions: smoking, morbid obesity, advanced cancer, refractory heart disease, chronic respiratory failure, chronic infection, non-adherence 2. Blood-typing, HLA testing

Cancer grading

1. Grade I: cells differ slightly from normal cells and are well differentiated 2. Grade II: cells are more abnormal and moderately differentiated 3. Grade III: cells are very abnormal and poorly differentiated 4. Grade IV: cells are immature and primitive and undifferentiated 5. Grade X: grade cannot be assessed

Arterial sources of stroke (3)

1. Intracranial vascular disease 2. Carotid vascular disease 3. Aortic arch

UTI categories

1. Upper UTI: pyelonephritis 2. Lower UTI: cystitis, urethritis, prostatitis 3. Uncomplicated UTI: normal urinary tract, usually only involve bladder, non-recurrent 4. Complicated UTI: structural/functional problem in urinary tract, hospital acquired, antibiotic resistance, immunocompromised, recurrent infections

Secondary prevention: Risk factor modification (4)

1. smoking cessation 2. diabetes control 3. aggressive cholesterol lowering 4. hypertension control

A nurse is reviewing the medical records of several clients who have come to the clinic. Each of the clients wears corrective lenses. For the client with which corrected visual acuity would the nurse need to include additional devices and strategies to address low vision?

20/80

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: A Alteration in tissue perfusion related to compromised circulation B Dysfunctional use of extremities related to muscle spasms C Impaired mobility related to stress associated with pain D Impairment in muscle use associated with pain on exertion

A Alteration in tissue perfusion related to compromised circulation

Cancer can cause changes in what component of Virchow's triad? A Blood coagulability B Vessel walls C Blood flow D Blood viscosity

A Blood coagulability

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? A 70-year-old male, with high cholesterol and hypertension A 40-year-old female with obesity and metabolic syndrome A 60-year-old male with renal insufficiency who is physically inactive A 65-year-old female with hyperhomocysteinemia and substance abuse

A 70-year-old male, with high cholesterol and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

A dietary modification for a patient with Ménière's disease would be: An increase in vitamin C to 1.5 g/day. Fluid restriction to 2 L/day. A decrease in sodium intake to 2,000 mg daily. An increase in calcium to 1 g/day.

A decrease in sodium intake to 2,000 mg daily.

After treatment and education of a patient with retinal detachment you know he understands how to care for his healing eye when he says the following, I should sleep flat without a pillow I should return to my regular weight lifting schedule I should apply ice packs I should not wear sunglasses so that my eye can heal faster

A patient with retinal detachment should avoid air travel due to air bubble inserted during surgery, anything that increases extraocular pressure, sleep with HOB elevated, application of ice packs and wearing sunglasses.

Which portion of the middle ear equalized pressure? A) Eustachian tube B) Cochlea C) Auricle D) Ossicles

A) Eustachian tube

When the nurse is gathering a history from a patient newly diagnosed with glaucoma, the patient reports the following statement to the nurse. Which statement would be consistent with the patient's diagnosis? A) I began seeing halos around lights and had dim vision B) I had a difficult time matching my blue socks C) My eyes began to tear and itch D) I could see the street signs better than my hand

A) I began seeing halos around lights and had dim vision

What is the nurse's priority while caring recently diagnosed with primary open-angle glaucoma? A) Preventing the risk for injury related to peripheral vision loss B) Treating chronic pain related to increased intraocular pressure C) Addressing the adverse effects of medication D) Teaching related to the new diagnosis of glaucoma

A) Preventing the risk for injury related to peripheral vision loss

Which term refers to surgical repair of the tympanic membrane? A) Tympanoplasty B) Myringotomy C) Tympanotomy D) Ossiculoplasty

A) Tympanoplasty

The nurse caring for the patient with Menieres disease restricts the following foods in the dietary plan. Select all that apply. A. Coffee B. Wine C. Baked Potato D. Cheese

A, B, D

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

A: Hypertension- The body responds to the vasopasm and a decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.

nonoptical aids

enlarged print, high-intensity lamps, daily living aids, high-contrast objects, positioning

22. An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney disease.

ANS: A Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.

. When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Loose, bloody stools c. Hypoactive bowel sounds d. Abdominal pain with palpation

ANS: B Loose, bloody stools at this time may indicate intestinal ischemia or infarction, and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.

31. The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure 137/88 mm Hg d. 25 mL urine output over last hour

ANS: C The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that β-blockers or other antihypertensive medications can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.

A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? Platelet count Activated clotting time (ACT) International normalized ratio (INR) Activated partial thromboplastin time (APTT)

Activated partial thromboplastin time (APTT)

Prostate cancer risks

African American, men 65+, family hx, diet high in red meats and high fat dairy

Risk factors for HIV transmission

Age (25-34), race, men who have sex with men, lack of safe sex habits, injected drugs and sharing needles or works

Cataract risk factors

Aging, other ocular conditions, corticosteroid use, smoking, poor nutrition, dehydration, UV light damage, chronic conditions

DVT treatments

Anticoagulation therapy, thrombolytic therapy, surgery, interventional radiology procedures

Manifestations of left brain damage

Aphasia, inability to remember words

16.ID: 809567309 A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? Keep the patient on bed rest. Assist the patient with walking several times. Have the patient sit in the chair several times. Place the patient on her side with knees flexed.

Assist the patient with walking several times. avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines

When teaching the client about Ménière's disease, which of the following diet changes should the nurse emphasize? Avoid foods high in sodium. Increase the amount of green leafy vegetables. Reduce the intake of milk and milk products. Increase fluid intake before meals.

Avoid foods high in sodium Because Ménière's disease causes a sensation of fullness or pressure in the ears that may be related to edema of the membranous labyrinth, a diet low in sodium is recommended. Green leafy vegetables will not affect Ménière's disease. Intake of milk and milk products will not affect Ménière's disease, but sodium intake will. Increased fluid intake before meals will not affect Ménière's disease, but sodium intake will.

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? A Pulsatile abdominal mass B Hyperactive bowel sounds in that area C Systolic bruit over the area of the mass D Subjective sensation of "heart beating" in the abdomen

B Hyperactive bowel sounds in that area

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: A Walking several times each day as an exercise program. B Keeping the heat up so that the environment is warm C Wearing TED hose during the day D Using hydrotherapy for increasing oxygenation

B Keeping the heat up so that the environment is warm The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain

With peripheral arterial insufficiency, leg pain during rest can be reduced by: A Elevating the limb above heart level B Lowering the limb so it is dependent C Massaging the limb after application of cold compresses D Placing the limb in a plane horizontal to the body

B Lowering the limb so it is dependent

The nurse is caring for a baseball player who reports getting hit in the head with a baseball 1 hour prior to admission to the ED. What assessment requires immediate reporting? A) Eye pain B) Flashing lights in the visual field C) Headache, pain, intensity rated as 2/10 D) Superficial head abrasion

B) Flashing lights in the visual field

What would the nurse expect when assessing a client with glaucoma? A) Reports of double vision B) Reports of halos around lights C) Intraocular pressure of 15 mmHg D) Soft globe on palpation

B) Reports of halos around lights

Which symptom is related to vertigo? A) Fainting B) Spinning sensation C) Syncope D) Loss of consciousness

B) Spinning sensation

Which statement describes benign paroxysmal positional vertigo (BPPV)? BPPV is stimulated by the use of certain medications, such as acetaminophen. The vertigo is usually accompanied by nausea and vomiting. The onset of BPPV is gradual. BPPV is caused by tympanic membrane rupture.

BPPV is a brief period of incapacitating vertigo that occurs when the position of the client's head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however, hearing impairment does not generally occur. The onset of BPPV is sudden and followed by a predisposition for positional vertigo, usually for hours to weeks but occasionally months or years. BPPV is thought to be caused by the disruption of debris within the semicircular canal. This debris is formed from small crystals of calcium carbonate from the inner ear structure, the utricle. BPPV is frequently stimulated by head trauma, infection, or other events.

The nurse is assessing the lower extremities of a patient with a possible DVT. Which of the following is not a reliable indicator of a possible DVT? A. Calf tenderness B. Edema of the extremity C. Homan's sign D. Increased circumference of affected extremity

C

Which of the following characteristics is typical of the pain associated with DVT? ADull ache BNo pain CSudden onset DTingling

C Sudden onset

Which symptoms may a client with Meniere disease report before an attack? A) Photosensitivity B) Lower blood pressure C) A full feeling in the ear D) Nystagmus

C) A full feeling in the ear

Which type of glaucoma presents an ocular emergency? A) Ocular hypertension B) Normal tension glaucoma C) Acute angle-closure glaucoma D) Chronic open-angle glaucoma

C) Acute angle-closure glaucoma

Which feature should a nurse observe during an ophthalmic assessment? A) Visual acuity B) Intraocular pressure C) Appearance of the external eye D) Internal eye function

C) Appearance of the external eye

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C. Slow and possibly fearful performance of tasks Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Oncologic emergencies: tumor lysis syndrome

Combination of two+ metabolic abnormalities: i. Hyperuricemia ii. Hyperphosphatemia iii. Hyperkalemia iv. Hypocalcemia

When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

D All of the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.

Which group of medications causes pupillary constriction? A) Adrenergic agonists B) Mydriatics C) Beta-blockers D) Miotics

D) Miotics

Which circumstance would cause the nurse to question an order to irrigate the ear canal? A) Ear pain B) Hearing loss C) Otitis externa D) Perforated tympanic membrane

D) Perforated tympanic membrane

The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is: AHormonal secretion BIndependent arterial wall activity CThe influence of circulating chemicals DThe sympathetic nervous system

DThe sympathetic nervous system

Ascites intervention

Diet education, medications, monitor weight/edema, monitor dehydration, assist in paracentesis/shunt

Diverticulosis interventions/education

Diet, medication, usually outpatient, rest, analgesics, possible surgery

Acute gastritis causes

Dietary, excessive aspirin/NSAID use

Gout nutrition education

Educate on lifestyle changes (decrease salt, fat, cholesterol), restrict foods high in purines, medication management, education on vitamin C

Cervical cancer risks

HPV, lack of screening

Aortic dissection treatments

HR/BP control Pain management Surgical repair

The nurse should monitor for which manifestation in a client who has undergone LASIK?

Halos and glare

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? Tamponade will soon occur. The renal arteries are involved. Perfusion to the legs is impaired. He is bleeding into the abdomen.

He is bleeding into the abdomen.

Hip injury complications/post op

Hemorrhage, shock, injury to bladder/urethra/intestines/rectum/abdominal organs, injury to pelvic vessels and nerves

Postoperative nursing assessment for a patient who has had a mastoidectomy should include observing for facial paralysis, which might indicate damage to which cranial nerve? First Fourth Seventh Tenth

Injury to the seventh cranial nerve, also known as the facial nerve, is a complication of a mastoidectomy, although rare. Hearing loss of less than 30 dB is a more common complication.

AKi dietary restrictions

K and phosphorus restricted diet, protein adjustments

The nurse is admitting a client with the diagnosis of Parkinson's disease. Whichassessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.

Masklike facies and a shuffling gait aretwo clinical manifestations of PD.

Myelosuppression

Nadir: the lowest point that blood counts will reach a. Onset varies with type and amount of drug used b. Typically, between day 7-14 c. Most dangerous time for the patient

1st thing you do when you suspect a stroke

Non-contrast CT scan (determines hemorrhagic vs ischemic)

PICOT question development

P: Population, patient, or problem I: Intervention, prognostic factor, exposure C: Comparison to intervention (if appropriate) O: Outcome you would like to measure or achieve T: Time

Stroke impairments from right-sided brain damage

Paralysis/weakness on left side of the bogy (hemiplegia), left visual deficit, spatial perceptual deficits

A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? Patient complains of chest pain with strenuous activity. Patient says muscle leg pain occurs with continued exercise. Patient has numbness and tingling of all his toes and both feet. Patient states the feet become red if he puts them in a dependent position.

Patient says muscle leg pain occurs with continued exercise. Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.

when administering a topical ocular medication to a patient, the nurse should: SATA Position the patient's head in a supine position Ask the patient to hold his or her breath during administration Apply the medication 2-3 inches above the conjunctival sac Have the patient keep his or her eyes closed for 3 to 5 minutes after administration.

Position the patient's head in a supine position Have the patient keep his or her eyes closed for 3 to 5 minutes after administration to promote optimal absorption.

Otitis media causes

Pressure on the tympanic membrane, infection

Oncologic Emergencies: Superior Vena Cava Syndrome

Respiratory support, VS, corticosteroids, anticoagulation if r/t clot

A basketball player after being hit on the head hard with a ball comes into the clinic complaining of having a sensation of a curtain coming across the vision of one eye, cobwebs, flashing lights, and sudden onset of numerous floaters. You immediately associate these S/S with what? corneal abrasion macular degeneration closed angle glaucoma retinal detachment

Retinal detachment is the seperation of the retinal pigment epithelim from the sensory layer resulting in having a sensation of a curtain coming across the vision of one eye, cobwebs, flashing lights, and sudden onset of numerous floaters

Which of the following is not a risk factor for cataracts: Aging Other Ocular Conditions Smoking Poor Nutrition Dehydration UV Light Damage Light Eye Color Age

Several studies indicate that the darker your irises, the more likely you are to develop several different types of cataracts. Eye color is associated with a greater risk of: Nuclear cataract (center of the lens) Cortical cataract (edges of the lens) Posterior subcapsular cataract (back of the lens)

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: A Familial tendency toward peripheral vascular disease B Smoking history CRecent exposures to allergens DHistory of insect bites

Smoking history The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

DVT patient education

Teach about modifying risk factors: -Ambulation -Compression stockings -SCD pump -Medication teaching (wafarin/heparin)

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Avoid fatty foods and exercise. Avoid situations that contribute to ischemic episodes. Take over-the-counter decongestants. Report changes in the usual pattern of chest pain

Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

Which instructions regarding swimming should the nurse give to a client who is recovering from otitis externa? Wear soft plastic earplugs. Insert a loose cotton earplug in the external ear. Wear a scarf. Avoid cold water.

The nurse should advise the client to wear soft plastic earplugs to prevent trapping water in the ear while swimming. Wear soft plastic earplugs to prevent trapping water in the ear while swimming. Cotton can be used, but if so it needs to be covered in petroleum jelly to prevent water from entering the external canal. Wearing a scarf does not help prevent or treat otitis externa. Swimming in cold water is not related to otitis externa.

The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching? Avoid daily exercise. Drink 8 to 10 glasses of fluid daily. Avoid unprocessed bran. Use laxatives weekly.

The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client should include unprocessed bran in the diet because it adds bulk, and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.

Which of the following is the most common site for a dissecting aneurysm? Sacral area Thoracic area Cervical area Lumbar area

The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

Aortic dissection patient education

Therapeutic regimen, routine follow-up, seek immediate help if pain returns

Characteristics of a thrombotic stroke

Type most often signaled by TIAs, commonly occurs during or after sleep, strong association with hypertension

20.ID: 809567339 The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? Assess output for renal dysfunction. Use IV fluids to maintain adequate BP. Use oral antihypertensives to maintain cardiac output. Maintain a low BP to prevent pressure on surgical site

Use IV fluids to maintain adequate BP. The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

Hemorrhagic stroke causes

Weakened vessel ruptures - intracranial aneurysms

The occupational health nurse is teaching a class on the risk factors for developing OA. Which is a modifiable risk for developing OA? a. Being overweight b. Increasing age c. Previous joint damage d. Genetic susceptibility

a. Being overweight

Oncologic emergencies: spinal cord compression

a. Breast, lung, prostate tumors b. Potential for irreversible paraplegia

Oncologic emergencies: carotid artery rupture

a. Head and neck cancers, minor oozing to blowout b. IV fluids and blood products

Osteoporosis interventions

adequate Ca, vitamin D, sunshine, medications (anticatabolic/bisphosphonates), hormone therapy, estrogen receptor modulators, calcitonin

risk factors of glaucoma

age, sex, AA, family hx, DM, CVD, migraine syndromes, myomia, eye trauma, prolonged corticosteroid use, and inflammatory processes

Glaucoma risk factors

age, sex, ethnicity, family hx, DM, CVD, migraine syndromes, nearsightedness, eye trauma, prolonged corticosteroid use, and inflammatory processes

irregularly curved cornea

astygmatism

21. When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

b. "It is very important that you stop smoking cigarettes." ANS: B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

3 components of EBP

best research evidence clinical expertise patient values

Sarcoma

bone/fat/vessels

Chronic gastritis causes

Ulcers, bacteria, autoimmune diseases, medications, alcohol, smoking, chronic reflux

Which manifestation is the most problematic for the client diagnosed with Ménière disease? Diaphoresis Vertigo Hearing loss Tinnitus

Vertigo is usually the most troublesome complaint related to Ménière disease. Other clinical manifestations include tinnitus, diaphoresis, and hearing loss.

systemic lupus erythematosus (SLE) risks

Women, African Americans, Hispanics

Cancer diagnosis methods

X-ray, CT, MRI, PET scan, ultrasounds, blood tests, biopsy, angiography (vascularity)

The type of seizure, also known as a petit mal seizure, that occurs more often in children between the ages of 4 and 12 years is the: absence seizure generalized seizure myoclonic seizure tonic clonic seizure

absence seizure

glaucoma

group of diseases of the eye characterized by increased intraocular pressure that results in damage to the optic nerve, producing defects in vision

optical aids

handheld magnifiers, glasses, antireflective lenses

nursing management of low vision

optimize remaining vision magnify and enhance image with vision aids promoting coping efforts promoting spatial orientation promoting mobility promoting home and community based care

The nurse is caring for an older client who has a severe hearing impairment. An appropriate nursing intervention would be to: encourage the client to learn sign language. write out questions and responses. reduce environment noise before speaking with the client. raise the voice to a higher pitch.

reduce environment noise before speaking with the client. In hearing-impaired clients, it is most important to reduce environmental noise before speaking with the client. Speaking in a higher pitch does not help the client hear; higher tones are usually lost first. Use written messages if the client cannot hear at all. Most older clients are unwilling to learn sign language.

Low vision is a general term describing visual impairment that

requires clients to use devices and strategies in addition to corrective lenses to perform visual tasks.

Intracerebral hemorrhage causes

ruptures vessel, HTN

Immediately after cataract surgery, it is important for the nurse to place the client in what position? flat in bed turned on affective side high Fowler's position semi-Fowler's position

semi-Fowler's position After surgery, place in semi-Fowler's position to decrease intraocular pressure in the affected eye. Lying flat in bed would increase intraocular pressure. Lying on the affected side would increase intraocular pressure. High Fowler's in not necessary; semi-Fowler's position is sufficient to decrease intraocular pressure in the affected eye.

Carcinoma

skin cancer

A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? Gender Smoking Ethnicity Co-morbidities

smoking Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.

open angle glaucoma

the most common form of glaucoma, where the trabecular meshwork gradually becomes blocked, causing a buildup of pressure

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It is a hereditary disease." "Is it possible that you are overusing aspirin." "It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "It is probably your nerves."

"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." Acute gastritis is often caused by dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate.

A client has undergone a cataract extraction with an intraocular lens implant. After providing discharge instructions, the nurse determines that the client needs additional teaching based on which statement? "I should wear the eye patch for the first 24 hours after surgery." "My vision will be back to normal immediately after surgery." "I might feel a scratchy sensation for the first couple of days." " I need to wear sunglasses if I'm outside."

"My vision will be back to normal immediately after surgery." After surgery, the client's vision gradually improves as the eye heals. Although clients with intraocular implants have functional vision on the first day after surgery, vision is stabilized when the eye is completely healed, usually within 6 to 12 weeks. To prevent accidental rubbing or poking of the eye, the client wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks. Sunglasses should be worn while outdoors during the day because the eye is sensitive to light. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days.

Stages of HIV/AIDS

1. HIV asymptomatic (Category A): a. Asymptomatic and 500 CD4 count 2. HIV symptomatic (Category B): a. May have complicated HIV infections 200-499 CD4 3. AIDS (Category C) a. Immune system significantly impaired < 200 CD4

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Placing oxygen and suction equipment at the bedside 5. Flushing the intravenous catheter to ensure that the site is patent

1, 2, 5, 6 Seizure precautions have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. Test-Taking Strategy: Focus on the subject, seizure precautions. Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for placing the bed in the high position and using a tongue blade.

Risk factors for incontinence/retention:

1. Incontinence: age, menopause, pregnancy, GU surgery, high-impact exercise, DM, stroke, obesity, cognitive disturbances, medications, lack of assistance 2. Retention: DM, prostate enlargement, urethral blockages, pelvic injuries, pregnancy, neurologic/myogenic disorders, medications

PAD manifestations

1. Intermittent claudication 2. Shiny, taut skin 3. Hair loss 4. Decreased peripheral pulses 5. Numbness/tingling in toes/feet 6. Pain 7. Critical limb ischemia

Categories of AKI

1. Prerenal AKI: most common, results from conditions that affect renal blood flow and perfusion a. Rapidly reversed if blood flow is restored 2. Intrinsic/intrarenal AKI: 50% of cases, results from damage to the functional kidney tissue a. Glomerular/microvascular injury b. Acute tubular necrosis 3. Postrenal AKI: <10% of cases, any condition that prevents urine excretion

Cancer staging

1. Stage 0: cancer in situ 2. Stage 1: localized to tissue of origin 3. Stage 2: limited local spread 4. Stage 3: extensive local and regional spread 5. Stage 4: metastasis

Barriers to transgender care

1. States that do not allow same-sex partners to make healthcare decisions 2. Insurance will not cover expenses 3. Many will seek care only in emergencies

The client diagnosed with Parkinson's disease (PD) is being admitted with a fever andpatchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations ofPD would explain these assessment data? 1. Masklike facies and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect .4. Lack of arm swing and bradykinesia.

2. Difficulty swallowing places the clientat risk for aspiration. Immobilitypredisposes the client to pneumonia.Both clinical manifestations place theclient at risk for pulmonarycomplications.

A client has been newly diagnosed with Meniere's disease. What is the nurse's priority of care for this client? A) Controlling the client's symptoms B) Encouraging the client to increase their dietary salt intake C) Reassuring the client that hearing loss is temporary D) Preparing the client for surgery

A) Controlling the client's symptoms

Match complaint with eye disorder: A. " I began seeing halos around lights and had dim vision." B. " I had a difficult time matching my blue socks." C. " My eyes began to tear and itch." D. " I can see the street signs better than my hand." 1- hyperopia 2- Conjunctivitis 3- Cataracts 4- Glaucoma

A. Glaucoma p. 1313 B. Cataracts C. Conjunctivitis D. Hyperopia Blurred vision, halos around lights and difficulty focusing and adjusting eyes in low lighting, loss of peripheral vision are classic signs of glaucoma. Glaucoma is related to peripheral vision loss and blindness, whereas, color is a feature related to central vision. Itchy and teary eyes are often associated with conjunctivitis. Hyperopia is a refractive error whereby people have excellent distant vision and near vision is blurry. Farsightedness is related to the eye having a shorter depth and, therefore, the visual image focuses beyond the retina.

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth.

A. Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

A: check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position

28. A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is developing a discharge teaching plan for the patient, which outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care

ANS: A Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease

4. A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

ANS: A Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.

24. The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

ANS: A Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the physician immediately because this is an emergency situation. Because pulses are marked prior to surgery, the nurse would know whether pulses were present prior to surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient's legs.

9. After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient places the hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor, and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon.

2. A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about a. low back pain. b. trouble swallowing. c. abdominal tenderness. d. changes in bowel habits.

ANS: B Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms.

27. A patient who is 2 days post-femoral-popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/LVN has the patient sit in a chair for 90 minutes. b. The LPN/LVN assists the patient to walk 40 feet in the hallway. c. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. d. The LPN/LVN places the patient in a Fowler's position for meals.

ANS: A The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.

17. Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Check the abdominal incision for any redness. d. Teach the reason for a prolonged recovery period.

ANS: B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.

8. When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."

ANS: B Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

26. The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.

ANS: B Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.

Which terms refers to the progressive hearing loss associated with aging? Presbycusis Exostosis Sensorineural hearing loss Otalgia

Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

7. The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. a serosanguineous drainage from the ulcer.

ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

19. A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.

ANS: C Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease.

After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

ANS: C The patient's presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.

The nurse is caring for a patient with peripheral artery disease. Based on assessment, which of the following clinical manifestations would be inconsistent with acute arterial occlusion? A. Pallor B. Paresthesia C. Hyperthermia D. Poikilothermia

C

30. Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

ANS: D Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs.

35. The nurse reviews the admission orders shown in the accompanying figure for a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question? a. Use of treadmill for exercise b. Referral for dietary instruction c. Exercising to the point of discomfort d. Combined clopidogrel and omeprazole therapy

ANS: D Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this prescription with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.

20. While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? a. "When I stand too long, my feet start to swell." b. "I get short of breath when I climb a lot of stairs." c. "My fingers hurt when I go outside in cold weather." d. "My legs cramp whenever I walk more than a block."

ANS: D Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

3. Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level.

ANS: D The decreased urine output suggests decreased renal perfusion, and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.

6. A patient at the clinic says, "I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should a. check for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. assess for the presence of the dorsalis pedis and posterior tibial pulses.

ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism (VTE).

5. A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.

ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply. SATA DASH diet Ingestion of strong acids Irritating foods Participation in highly competitive sports Overuse of aspirin

Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. A DASH diet is an acronym for Dietary Approaches to Stop Hypertension, which would not cause gastritis. Participation in competitive sports also would not cause gastritis.

A patient is seen in the vision clinic. The patient has been diagnosed with glaucoma. Which of the following would the nurse expect to be in the treatment plan for this patient as the initial topical medication? A. Mydriatic B. Antifungal C. Beta Agonist D. Miotic

Answer C. Beta blockers decrease the production of aqueous humor with resultant decrease in IOP and are the preferred initial topical medication. Mydriatics, antifungals, and miotics would not be appropriate for those diagnosed with glaucoma. see ch. 49 answer sheet

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute Urine output of 150 ml/hour and heart rate of 45 beats/minute Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

High doses of which medication can produce bilateral tinnitus? Meclizine Dimenhydrinate Aspirin Promethazine

At high doses, aspirin toxicity can produce bilateral tinnitus. Meclizine and dimenhydrinate are used for nausea and vomiting related to motion sickness. Antiemetics, such as promethazine suppositories, help control nausea and vomiting and vertigo through an antihistamine effect.

Buerger's disease is characterized by all of the following except: A Arterial thrombosis formation and occlusion B Lipid deposits in the arteries C Redness or cyanosis in the limb when it is dependent D Venous inflammation and occlusion

B Lipid deposits in the arteries

With peripheral arterial insufficiency, leg pain during rest can be reduced by: A Elevating the limb above heart level B Lowering the limb so it is dependent C Massaging the limb after application of cold compresses D Placing the limb in a plane horizontal to the body

B Lowering the limb so it is dependent

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: A Familial tendency toward peripheral vascular disease B Smoking history C Recent exposures to allergens D History of insect bites

B Smoking history Question 18 Explanation: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

The nurse is caring for a baseball player who reports getting hit in the head with a baseball 1 hr prior to admission. Which of the following assessments requires immediate reporting to the physician? A. Eye pain B. Flashing lights and floaters in the visual field C. Headache, pain intensity 4/10 D. Superficial head abrasion

B - From answer sheet: Eye pain is not always directly associated with head trauma. It may be result from a variety of causes and does not establish imminent danger requiring immediate reporting. Flashing lights, floaters, cobwebs or a shade across the vision of one eye reported in retinal detachment which is often associated with head trauma. A mild headache can be caused by many factors. One would expect serious complications of head trauma to have more than a subtle headache relieved by Acetaminophen. A superficial head abrasion is not considered requiring emergent care.

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? A An acute obstruction in the vessels of the legs B Peripheral vascular problems in both legs C Diabetes D Calcium deficiency

B Peripheral vascular problems in both legs Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

Which statement by the patient diagnosed with viral conjunctivitis indicates that more teaching is necessary? A) I will wash my hands frequently B) I will use a washcloth to clean both my eyes, starting with the infected eye and moving to the uninfected eye C) I will avoid contact with other people until my symptoms are gone D) I will discard any leftover eye medication when the infection is gone

B) I will use a washcloth to clean both my eyes, starting with the infected eye and moving to the uninfected eye

A client who has come to the clinic for evaluation is diagnosed with glaucoma. The client asks the nurse "what is this disease?" Which information would the nurse most likely include in the response? A) The conjunctiva becomes inflamed and irritated B) Increased pressure in the eye causes damage to the optic nerve C) The lens becomes cloudy, causing vision to be impaired D) The retina separates from the sensory layers of the eye

B) Increased pressure in the eye causes damage to the optic nerve

Which test uses a tuning fork shifted between 2 positions to assess hearing? A) Weber B) Rinne C) Watch trick D) Whisper

B) Rinne

When using a Snellen alphabet chart, a nurse records a client's vision as 20/40. Which statement best describes 20/40 vision? A) The client has alterations in near vision and is legally blind B) The client can see at 20 feet what the person with normal vision sees at 40 feet C) The client can see at 40 feet what the person with normal vision sees at 20 feet D) The client has a 20% decrease in acuity in one eye, and 40% decrease in the other eye

B) The client can see at 20 feet what the person with normal vision sees at 40 feet

The part of the ear that helps with hearing and balance is A) The outer ear B) The inner ear C) The central auditory system D) The brain and pathways

B) The inner ear

Which manifestation is the most problematic for the client diagnosed with Meniere disease? A) Tinnitus B) Vertigo C) Hearing loss D) Diaphoresis

B) Vertigo

Which characteristic of a patient's recent seizure is consistent with a focal seizure? A. The patient lost consciousness during the seizure. B. The seizure involved lip smacking and repetitive movements. C. The patient fell to the ground and became stiff for 20 seconds. D. The etiology of the seizure involved both sides of the patient's brain.

B. The seizure involved lip smacking and repetitive movements. The most common complex focal seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.

The nurse provides information to the caregiver of a 68-year-old man with epilepsy who has tonic-clonic seizures. Which statement, if made by the caregiver, requires further teaching? A. "It is normal for a person to be sleepy after a seizure." B. "I should call 911 if breathing stops during the seizure." C. "The jerking movements may last for 30 to 40 seconds." D. "Objects should not be placed in the mouth during a seizure."

B. "I should call 911 if breathing stops during the seizure." Caregivers do not need to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred. Altered breathing is a clinical manifestation of a tonic-clonic seizure. Contact emergency medical services (or call 911) if breathing stops for more than 30 seconds. No objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.

The following statement by the patient diagnosed with viral conjunctivitis indicates further teaching is necessary? (select all that apply): A. I will wash my hands frequently B. I will use a washcloth to clean both my eyes, starting with the infected eye and moving to the uninfected eye. C. I will avoid contact with other people until my symptoms are gone. D. I will complete my course of antibiotic eye drops even if symptoms subside.

B. I will use a washcloth to clean both my eyes, starting with the infected eye and moving to the uninfected eye. See answer sheet for NCLEX Review Questions Ch. 40 Handwashing is a practice which reduces the transmission of germs in general. The specific technique of cleaning the uninfected eye and then the infected eye will reduce the potential for conjunctival spread. Contact with other persons is generally discouraged for at least 24 hours after antibiotic use in the case of bacterial conjunctivitis; viral conjunctivitis is also highly contagious but is not treated with antibiotics; symptoms may persist for 2 weeks. It may not be a realistic goal to keep a person isolated for this amount of time. Medication is not typically prescribed for viral conjunctivitis; it is usually a self limiting process.

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy

B: Surgical clipping of they aneurysm- Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall

B: Talk about ADLs that are familiar to the patient- during rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him. Conversation by the nurse and family should address ADLs that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed with verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless.

During the nurse's initial assessment of an elderly woman with open-angle glaucoma, what symptoms might the history reveal? light flashes in both eyes Blurred or tunnel vision Acute severe eye pain Central vision loss

Blurred or tunnel vision Symptoms of open-angle glaucoma may include blurred vision, tunnel vision, difficulty focusing on near objects, and halos around lights. Light flashes are symptomatic of retinal detachment, not glaucoma. Acute severe eye pain is a manifestation of acute angle-closure glaucoma, not open-angle glaucoma. Watery drainage from the eyes is not a manifestation of glaucoma. Central vision loss is characteristic of macular degeneration.

Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis? "My eyes feel like they are on fire." "It feels like there is something stuck in my eye." "My eyelids were stuck together this morning." "My eyes hurt when I'm in the bright sunlight."

Burning, a sensation of a foreign body, and pain in bright light (photophobia) are signs and symptoms associated with any type of conjunctivitis. The drainage related to bacterial conjunctivitis is usually present in the morning, and the eyes may be difficult to open because of adhesions caused by the exudate.

Varicose veins can cause changes in what component of Virchow's triad? ABlood coagulability BVessel walls CBlood flow DBlood viscosity

C Blood flow

After assessing a client's visual acuity, the nurse determines that the client's vision is normal. The nurse documents this as A) Astigmatism B) Hyperopia C) Emmetropic D) Myopia

C) Emmetropic

Which precaution should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance? A) Encourage the client to move the head slowly B) Recommend that the client keep his eyes closed C) Have the client wait for help before moving D) Restrict the client from focusing on one spot

C) Have the client wait for help before moving

You are working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased for several hours. What should you direct the caller to do first? A) Please call your physician B) Apply a cool compress to your eyes C) If you are wearing contact lenses, remove them D) Take an over-the-counter antihistamine

C) If you are wearing contact lenses, remove them

A patient, who is seen in the vision clinic, has been diagnosed with glaucoma. What initial topical medication would the nurse expect to be included in the treatment plan for this patient? A) Mydriatic B) Antifungal C) Beta blocker D) Miotic

C) Beta blocker

Which physical finding should be reported to the physician? A) Pearly gray or pink tympanic membrane B) Dense whitish ring at the circumference of the tympanum C) Bulging red or blue tympanic membrane D) Cone of light at the innermost part of the tympanum

C) Bulging red or blue tympanic membrane

The patient with significant visual impairment requires assistance with ADLs. The nurse provides support when serving food by performing which action? A) Leaving the tray on the patient's bedside table B) Serving hot food as quickly as possible C) Describing the food on the tray in terms of the face of a clock D) ensuring all food is soft

C) Describing the food on the tray in terms of the face of a clock

The nurse is assessing an 86 year old patient who is hearing impaired. Which intervention should the nurse implement? A) Obtain an ear wick B) Shout into the better ear C) Lower your voice pitch while facing the client D) Ask the family to go home and get the client's hearing aid

C) Lower your voice pitch while facing the client

A client with a head injury is brought to the emergency department. The nurse suspects that the client may have a perforated tympanic membrane based on which assessment finding? A) Epistaxis B) Periauricular swelling C) Otorrhea D) Reports of tinnitus

C) Otorrhea

A client is prescribed eye drops which cause mydriasis. When evaluating the effect of these drops, the nurse would assess for A) Pupil constriction B) Reduced conjunctival redness C) Pupil dilation D) Reduced intraocular pressure

C) Pupil dilation

Which diagnostic test distinguishes between conductive and sensorineural hearing loss? A) Audiometry B) Weber test C) Rinne test D) Whisper test

C) Rinne test

Which description by client reporting vertigo would concern you the most? A) Dizziness with hearing loss B) Episodic vertigo C) Vertigo without hearing loss D) "Merry go round" vertigo

C) Vertigo without hearing loss

The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A. A 42-year-old patient with multiple sclerosis who was admitted with sepsis B. A 72-year-old patient with Parkinson's disease who has aspiration pneumonia C. A 38-year-old patient with myasthenia gravis who declined prescribed medications D. A 45-year-old patient with amyotrophic lateral sclerosis who refuses enteral feedings

C. A 38-year-old patient with myasthenia gravis who declined prescribed medications Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will develop a myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest.

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c.individuals with hypertension and diabetes d. those who are obese with high dietary fat intake

C: Individuals with hypertension and diabetes- The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect

C: Administer ordered antihypertensives and platelet inhibitors- medication administration is within the scope of practice for an LPN. Assessment and teaching are within the scope of practice for the RN.

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque

C: Circulation through the circle of Willis may provide blood supply to the affected area of the brain. The communication between cerebral arteries in the circle of Willing provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. ALl areas of the brain require constant blood supply, and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia cause by many factors.

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

C: Teach the patient to care consciously for the affected side- unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

C: The brain area perfused by the affected artery- clinical manifestation of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.

An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes

C: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.

The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's: usual pattern of elimination. activity levels. alcohol consumption. current medications.

Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause.

A client does not like to wear a ski helmet while skiing because he is unable to hear other skiers around him as clearly. The ski helmet would interfere with the __________ of sound. Air conduction Bone conduction Nerve conduction Middle ear conduction

Correct Answer: Air conduction Rationale: Air conduction begins when noise enters the external ear canal and travels to the middle ear. Material covering the external auditory canal would interfere with sound waves entering the canal. The nerves related to hearing are located in the inner ear. Sound is interpreted by vibrations in the inner ear. Middle ear conduction is not a mechanism of hearing. Bone conduction occurs when the bones of the middle ear vibrate.

A nurse is working with a client who experienced the sudden onset of dizziness, nausea, and hearing loss. A diagnosis of Meniere's disease was made. The nurse should instruct the client to: Avoid tobacco, alcohol, and caffeine. Take OTC medications for the nausea. Stay in bed until symptoms subside. Use tranquilizers to help in coping with the disease.

Correct Answer: Avoid tobacco, alcohol, and caffeine. Rationale: Any drug or medication that may cause vertigo should be avoided. Tobacco, alcohol, and caffeine can cause dizziness. A client should not self-medicate with OTC medications. The symptoms of Meniere's disease can range from several minutes to hours or days in length. Bed rest should be avoided. Tranquilizers, or any medication that may cause vertigo, should be avoided.

Phenylephrine (Neo-Synephrine) is administered to a client before a diagnostic procedure. The client education about this medication should include: Driving may be difficult. Tears will be yellow. May cause burning. Sunlight will improve vision.

Correct Answer: Driving may be difficult. Rationale: Phenylephrine causes pupillary dilation. The nurse should inform the client that driving with eyes dilated may cause difficulty, especially on a sunny day. Patients should be instructed to wear sunglasses to block ultraviolet (UV) exposure. The pupils are unable to react to or decrease the amount of light entering the eye. Burning is an adverse reaction to phenylephrine. Medications that numb the eye, such as Proparacaine, will cause the tears to be yellow.

A client complains that sometimes there appears to be gnats in his field of vision. The nurse realizes the client is talking about: Floaters. Conjunctivitis. Nystagmus. Strabismus.

Correct Answer: Floaters. Rationale: The vitreous gel is made up mainly of water with a collagen framework. The collagen network can be aggregated by vitreous collapse due to aging and form opacities, which cast shadows on the retina. These shadows are referred to as floaters. The client often describes this as seeing gnats or a fine filament floating in the line of sight. Conjunctivitis is an inflammation of the conjunctiva. The main symptom is a discharge from the eyes. Nystagmus is an involuntary tremor or jerky movement of the eyeball. Strabismus is a functional misalignment of the extraocular muscles that causes the eyes not to focus together.

An examination of a client indicates there is limited central vision. This would indicate a problem with the: Macula. Lens. Sclera. Extraocular muscles.

Correct Answer: Macula. Rationale: The center of the retina, called the macula, is where the greatest numbers of cone receptors are located for central and color vision. The sclera is the outer protective layer of the eyeball that helps maintain its shape. The lens is the focusing structure of accommodation. The extraocular muscles move the eyeball.

Presbycusis is the loss of hearing that gradually occurs in most individuals as they grow older. This is usually a __________ hearing disorder. Sensorineural Conductive Mixed Air conduction

Correct Answer: Sensorineural Rationale: Presbycusis is usually a sensorineural hearing disorder caused by gradual changes in the inner ear as a result of loss of hair cells in the organ of Corti. There can be conductive causes of hearing loss, but sensorineural disorders are more common. There could also be mixed causes of hearing loss, but these are not as common as sensorineural. Interference of air conduction is not the result of aging.

The nurse is caring for a client newly diagnosed with glaucoma. The client is asymptomatic except for the increased intraocular pressure detected during a routine eye examination. When developing a plan of care for this client, which of the following goals should have the highest priority? Stress importance of compliance with glaucoma eyedrops. Assess for fall injuries. Consider home maintenance issues. Discuss risk factors.

Correct Answer: Stress importance of compliance with glaucoma eyedrops. Rationale: All of the goals should be part of a nursing care plan for a client with glaucoma. However, this client is asymptomatic and has not suffered any vision loss. To prevent vision loss, the importance of client compliance with glaucoma eyedrops to decrease the intraocular pressure should be given the highest priority. Discussion of risk factors is important, but the eyedrops are the most effective method of decreasing the chance of vision loss. Assessing for fall injuries and home maintenance issues are more relevant to clients who already have vision loss.

During an initial examination of the eye, the intraocular pressure should be measured. The nurse would use a _______________ to determine to pressure. Tonometer Ophthalmoscope Pen light Snellen acuity chart

Correct Answer: Tonometer Rationale: A tonometer is used to measure the intraocular pressure. An ophthalmoscope is used to view the fundus of the eye by viewing through the pupil. A pen light is used for external examination of the eye. The Snellen acuity chart is used to measure visual acuity.

The nurse is caring for a client with a hearing deficit who will be discharged soon. Which of the following should be included in discharge planning to ensure the home is environmentally safe? Visual fire safety provisions Housekeeping services Sign language classes An interpreter

Correct Answer: Visual fire safety provisions Rationale: It is important to ensure that the home environment is environmentally safe. Since smoke detectors indicate when smoke is present, it is necessary to install a device that alerts the client with a visual signal. Housekeeping services are not a need specific to a client with a hearing deficit. Sign language classes and an interpreter are not factors in making an environment safe.

A significant cause of venous thrombosis is: A Altered blood coagulation B Stasis of blood C Vessel wall injury D All of the above

D All of the above

A client presents with a foreign body protruding from his eye. What is the nurse's most important intervention? A) Irrigate the eye with sterile saline B) Assess visual acuity with a Snellen chart C) Remove the foreign body with sterile forceps D) Patch both eyes until seen by the ophthalmologist

D) Patch both eyes until seen by the ophthalmologist

The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is: A Hormonal secretion B Independent arterial wall activity C The influence of circulating chemicals D The sympathetic nervous system

D The sympathetic nervous system

Which finding should be immediately reported to the physician? A) A change in color vision B) Crusty yellow drainage on the eyelashes C) Increased lacrimation D) A curtain like shadow across the visual field

D) A curtain like shadow across the visual field

Before giving a beta-adrenergic blocking glaucoma agent, you would make additional assessments and notify the physician if the client makes which statement? A) My blood pressure runs a little high if I gain too much weight B) Occasionally I have palpitations, but they pass very quickly C) My joints feel stiff today, but that's just my arthritis D) My pulse rate is a little low today because I take digoxin

D) My pulse rate is a little low today because I take digoxin

In discharge teaching after cataract surgery, the client and family should be told to immediately report which symptom to the physicians? A) A scratchy sensation in the operative eye B) Loss of depth perception with the patch in place C) Poor vision 6-8 hours after patch removal D) Pain not relieved by prescribed medication

D) Pain not relieved by prescribed medication

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B. A 28-year-old male who uses marijuana after chemotherapy to control nausea. C. A 42-year-old female who takes oral contraceptives and has migraine headaches. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco. Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.

Which of the following children is at risk of recurrent otitis media (OM)? An 18-month-old infant who lives with a smoker A 2-year-old child who has had two ear infections in the past 6 months A 6-month-old infant who has a sibling who had tubes inserted at 3 years of age An 18-month-old infant who has had three episodes of ear infections in a 5-month period

D. A first episode of OM that occurs within 3 months of life increases risk of recurrent OM. Recurrent OM is three episodes within the past 3 months or four episodes within the past year.

When assessing for an arterial and venous ulcer, which of the following characteristics are consistent with arterial ulcers? A. Pink or beefy red with granulated tissue B. May have severe edema C. Darkened color tissue in gaiter area D. Pale and cool extremity

D. Pale and cool extremity

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

D. Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

D: Having the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.

The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

D: Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning- the patient and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the patient. It is uncommon for patients with major strokes to return completely to pre stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient's specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

D: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

A significant cause of venous thrombosis is: A Altered blood coagulation B Stasis of blood C Vessel wall injury D All of the above

DAll of the above

Hepatitis A transmission

Fecal-oral route, poor sanitation, person-to-person contact, waterborne, food borne

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Stabilizing heart rate and blood pressure and easing anxiety Increasing blood pressure and reducing mobility Decreasing blood pressure and increasing mobility Increasing blood pressure and monitoring fluid intake and output

For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.

Parkinson's disease manifestations

Gradual onset, symptoms progress slowly over time Cardinal signs: TRAP Tremor Rigidity of muscles Akinesia/Bradykinesia Postural instability (air/balance)

Stroke risk factors (modifiable)

HTN, heart disease, A-fib, DM, smoking, obesity, sleep apnea, sedentary lifestyle, HLD, drugs/alcohol

19.ID: 809567305 A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? Tamponade will soon occur. The renal arteries are involved. Perfusion to the legs is impaired. He is bleeding into the abdomen.

He is bleeding into the abdomen. The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

"A patient with hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to: a. Avoid alcohol for the first 3 weeks b. Use a condom during sexual intercourse c. Have family members get an injection of immunoglobin d. Follow a low-protein, moderate-carbohydrate, moderate-fat diet

Hepatitis B virus may be transmitted by mucosal exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

Characteristics of subarachnoid hemorrhage

High initial mortality, symptoms of meningeal irritation, caused by rupture of intracranial aneurysm, associated with sudden, severe headache

. A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver? Low-fat diet High-protein diet Calorie-restricted diet High-carbohydrate diet

High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone causing which of the following?

If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.

Oncologic Emergencies: pericardial effusion/cardiac tamponade

Immediate notification of AP is 1st step

When educating a client about acute angle-closure glaucoma, what point should the nurse emphasize to the client about this condition? Immediately report symptoms to your physician. Do not use medications that cause pupil constriction. Wear sunglasses when outdoors. Lie down for 30 minutes until symptoms disappear.

Immediately report symptoms to your physician. Acute angle-closure glaucoma is an emergency condition that must be treated immediately. Darkness and emotional stress cause pupil dilation, which can trigger the condition. Medications cause pupil constriction do not worsen this condition. Sunlight does not trigger this condition. Lying down will not help; it could only make the condition worse.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Risk for injury related to edema Impaired gas exchange related to increased blood flow Ineffective peripheral tissue perfusion related to venous congestion Excess fluid volume related to peripheral vascular disease

Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

Side effects of dialysis and renal transplant

Infection, cardiovascular disease, cancer, recurrence of disease

A client presents to the ED reporting a chemical burn to both eyes. Which is the priority nursing intervention? Assess visual acuity. Assess the pH of the corneal surface. Irrigate both eyes. Obtain the Material Safety Data Sheet (MSDS).

Irrigate both eyes. The eyes should immediately be irrigated to remove the chemical and preserve the eye. If the chemical is allowed to remain on the eye surface, it may cause ulcerations and permanent damage to the eye. It is appropriate to obtain the MSDS and assess the pH of the corneal surface after irrigation has begun. Irrigation should continue until the pH normalizes. Visual acuity can be assessed once the emergent phase is over.

Manifestations of right brain damage

Left homonymous hemianopsia, agnosia, quick impulsive behavior, neglect of the left side of the body

A nurse practitioner examines a patient and documents a best corrected visual acuity (BCVA) ratio in his better eye that qualifies him for government financial assistance based on the definition of legal blindness. What is that ratio?

Legal blindness is a condition of impaired vision in which a person has a BCVA that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less

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

Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which can affect both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly, but sees near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? Stop smoking. Wear antiembolic stockings daily to assist with blood return to the heart. Keep your feet elevated above your heart. Do not cross your legs for more than 30 minutes at a time.

Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

Otitis media treatments

Oral antibiotics, myringotomy, tympanovstomy tube, mastoidectomy (chronic cases)

The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be? 2.0-3.0 7.0-8.0 4.0-5.0 5.0-6.0

Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

Which condition is characterized by the formation of abnormal spongy bone around the stapes? otitis media otitis externa middle ear effusion otosclerosis

Otosclerosis is more common in females than males and is frequently hereditary. A middle ear effusion is denoted by fluid in the middle ear without evidence of infection. Chronic otitis media is defined as repeated episodes of acute otitis media, causing irreversible tissue damage and persistent tympanic membrane perforation. Otitis externa refers to inflammation of the external auditory canal.

Stroke impairments from left-sided brain damage

Paralysis/weakness on right side of body (hemiplegia), right visual field deficit, aphasia, communication loss, impaired language comprehension

17.ID: 809565397 A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? Paralysis Paresthesia Crampiness Referred pain

Paresthesia The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.

BPH s/sx

Poor urine flow, nocturia, frequent urge to urinate, difficulty starting stream

Which type of cataract can develop quickly and affects one's reading and night vision?

Primarily affecting one's reading and night vision, this type of cataract begins as a small opaque or cloudy area on the posterior (back surface) of the lens. It is called subcapsular because it forms beneath the lens capsule which is a small sac or membrane that encloses the lens and holds it in place. Subcapsular cataracts can interfere with reading and create halo effects and glare around lights. People who use steroids or have diabetes, extreme nearsightedness, and/or retinitis pigmentosa may develop this type of cataract. Subcapsular cataracts can develop rapidly and symptoms can become noticeable within months.

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: aids in weight reduction. reduces stress. decreases venous congestion. increases high-density lipoprotein (HDL) level.

Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.

A middle-aged female patient is being treated with the Epley maneuver, which is designed to reposition the canalith by having the patient perform quick movements of the head. The nurse should recognize that this patient likely has a history of what health problem? Benign paroxysmal positional vertigo (BPPV) Acoustic neuroma Otalgia Presbycusis

Repositioning techniques can be used to treat vertigo, such as the Epley maneuver. The maneuver is designed to reposition the canalith and involves quick movements of the head. The noninvasive procedure is performed by placing the patient in a sitting position and turning the head to a 45-degree angle on the affected side and 30 to 45 degrees backward. Then the patient is quickly moved to the supine position. This technique is not used in the treatment of otalgia, presbycusis, or acoustic neuroma.

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? Application of topical antibiotics to venous ulcers Maintaining the patient's legs in a dependent position Administration of oral and/or subcutaneous anticoagulants Teaching the patient the correct use of compression stockings

Teaching the patient the correct use of compression stockings CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address? The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; therefore, the care plan should include reporting signs of premature labor. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest. The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.

The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

Which type of cataract is most associated with glare? Nuclear Cortical Posterior Subscapular

The most common symptom from cortical cataracts is glare, especially from headlights while night driving. A cortical cataract forms in the shell layer of the lens known as the cortex and gradually extends its "spokes" from the outside of the lens to the center. These fissures can cause the light that enters the eye to scatter, creating problems with blurred vision, glare, contrast and depth perception. People with diabetes are at risk for developing cortical cataracts.

Which nursing suggestion would be most helpful to the client with recurrent otitis externa? Use a cotton applicator to ensure that the ear canal is dry. Flush the ear with hydrogen peroxide Avoid lying on the side of the affected ear Place ear plugs into the ears before swimming

The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, he or she advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.

A legally blind client is in pre-op area prior to an appendectomy. What steps does the nurse take to effectively communicate with this client ? Make direct eye contact with the client when communicating. Sit near the client to provide reassurance of the strange surroundings. Notify the client prior to touching the client. Inform the client that the nurse will be working nearby.

The nurse should announce upon arrival the bedside every time because many voices sound similar. The nurse should use the client's name initially so the client knows the nurse is communicating with the client directly. The nurse should speak before touching the client as not to startle the client. The nurse should notify the client when approaching and leaving the bedside each time. Orient the client to their surroundings using verbal descriptions and directions such as left, or right.

Tinnitus is a common symptom to many underlying disorders such as (SATA) ototoxic substances alcoholism Ménière disease ADHD thyroid disease

Tinnitus is another common symptom of an underlying disorder of the ear that is associated with hearing impairment and loss, ototoxic substances and a variety of hearing disorders (otosclerosis, Ménière disease, acoustic neuroma) and systemic disorders (thyroid disease, neurologic disorders). Tinnitus may range from mild to severe and is frequently described as a roaring, buzzing, or hissing sound in one or both ears. While some feel that certain additives and foods such as alcohol, sodium and caffeine can aggravate tinnitus, they are not usually the root cause.

A nurse who is responsible for planning many of the aspects of care on a subacute geriatric unit is aware of the high incidence and prevalence of vestibular disorders among older adults. In individuals with these disorders, the nurse should identify what consequent nursing diagnosis? Risk for falls related to vestibular disorder Risk for impaired tissue integrity related to vestibular disorder Risk for chronic confusion related to vestibular disorder Risk for aspiration related to vestibular disorder

Vestibular disorders are implicated in many falls among older adults. Vestibular disorders are unlikely to contribute to aspiration, cognitive deficits, or impaired tissue integrity.

A registered nurse is orientating a group of nursing assistants at a large long-term care facility. A high percentage of residents have some form of hearing impairment, so the nurse is teaching appropriate communication strategies to the assistants. The nurse should teach these staff members to: Avoid interactions that cannot be communicated using gestures. Use writing as the primary communication strategy with residents who are hearing impaired. Pause more frequently than usual when speaking to the individual. Use simple concepts, simple vocabulary, and monosyllables whenever possible.

When speaking with people who are hearing impaired, it is important to speak slowly and distinctly, pausing more frequently than you would normally. This does not mean, however, that every concept that is discussed must be simple or that multisyllabic words cannot be used when appropriate. Writing can be a useful tool, but it is rarely the primary means of communication with an individual.

A client is being taught about taking timolol (Timoptic). Which of the following side effects should the client report to a healthcare provider? darkening of the iris stinging in the eyes bitter taste in your mouth difficult breathing

difficult breathing Breathing difficulty, worsening vision, or increased sweating are side effect that should be reported immediately to a healthcare provider. Stinging in the eyes is common with dorzolamide (Trusopt), not timolol. Bitter taste in the mouth is common with dorzolamide (Trusopt), not timolol (Timoptic). Darkening of the iris develops with latanoprost (Xalatan), not timolol (Timoptic).

An acoustic neuroma is a benign tumor of the eighth cranial nerve; the CN most responsible for swallowing sensorineural loss facial sensation hearing and balance

eighth cranial nerve is the cranial nerve most responsible for hearing and balance. It usually arises within the internal auditory meatus. An acoustic neuroma is a slow-growing tumor and attains considerable size before it is correctly diagnosed. The patient usually experiences loss of hearing, tinnitus, episodes of vertigo, and staggering gait. As the tumor becomes larger, painful sensations of the face may occur on the same side, as a result of the tumor's compression of the fifth cranial nerve (trigeminal nerve) resulting in facial numbness (paresthesia) and pain. Diagnosis is suggested by unilateral sensorineural hearing loss; the Weber and Rinne test may be useful in assessing asymmetric hearing loss

Lymphoma/Multiple Myeloma

immune

medical blindness definition

no light perception

Osteoporosis risks

post-menopausal women, advanced age, low calcium intake, low vitamin D intake, Caucasian/Asian, sedentary, corticosteroids

Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?

viral