A MDC 1 EXAM 2

A nurse is performing an eye examination. Which question would not be included in the examination?

"Are you able to raise both eyebrows?"

After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. Which client statement indicates that the outcome of the teaching plan has been met?

"I should avoid pulling or pushing any object that weighs more than 15 lbs."

The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided?

"I will avoid prolonged sitting or walking."

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer?

"This test measures peripheral vision and detects gaps in the visual field."

A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate?

"You'll need to use the drops for the rest of your life to control the glaucoma."

The ophthalmologist tells a patient that he has increased intraocular pressure (IOP). The nurse understands that increased pressure resulting from optic nerve damage is indicated by a reading of:

>21 mm Hg.

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

Acute angle-closure

The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately?

Acute angle-closure glaucoma

Which type of glaucoma presents an ocular emergency?

Acute angle-closure glaucoma

The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client's lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse?

Call the physician to inform them of the findings

A client is examined due to recent vision changes and is diagnosed with myopia. What is the cause of this client's vision change?

Elongated eyeballs

A nurse is caring for a client who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.)

Encouraging the client to care for the residual limb Allowing the client to express grief Introducing the client to local amputee support groups.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?

Fat embolism

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has sustained a fracture. The nurse suspects which complication?

Fat embolism syndrome

A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition?

Hyperopia

The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis?

Identification of opacities on the lens

A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which of the following describes the desired effects of this procedure?

Improve outflow drainage

The client with chronic open-angle glaucoma is receiving timolol (Timoptic) eye drops. Which evaluation finding would indicate to the nurse the treatment is working?

Intraocular pressure 15 mm Hg

A client is exhibiting diminished range of motion, loss of flexibility, stiffness, and loss of height. The history and physical findings are associated with age-related changes of which area?

Joints

A nurse is caring for a client who recently underwent a total hip replacement. What is the best action by the nurse for client care?

Limit hip flexion of the client's hip when the client sits up.

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:

Loss of accommodative power in the lens.

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?

Myopia

There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for:

Ophthalmoscopy.

A client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. What complication should the nurse interpret as the findings?

Osteomyelitis

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate?

Presbyopia

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder?

Prolonged use of corticosteroids

The nurse realizes that a client understands how to correctly instill ophthalmic medications when the client:

Pulls the tissue near the cheek downward to instill medication.

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?

Retinal Angiography

A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign?

The presence of halos around lights

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment?

To prevent vision loss

To straighten the ear canal in an adult for examination, the nurse practitioner would grasp the auricle and pull it

Up and backward.

A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which exercise would the nurse be most likely to suggest?

Walking

Which of the following factors would the nurse need to keep in mind about the focus of the initial history when assessing a new client with a musculoskeletal problem?

Any chronic disorder or recent injury

The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform?

Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye.

A client has undergone arthroscopy. After the procedure, the site where the arthroscope was inserted is covered with a bulky dressing. The client's entire leg is also elevated without flexing the knee. What is the appropriate nursing intervention required in caring for a client who has undergone arthroscopy?

Apply a cold pack at the insertion site.

A client diagnosed with a cataract comes into the clinic. What assessments should the nurse observe in this client?

Blurred or cloudy visual image

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

Demonstrate eyedrop instillation

A health care provider diagnoses primary osteoporosis in a client who has lost bone mass. For which client is primary osteoporosis most common?

Elderly postmenopausal woman

Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests?

Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss.

The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. The client is visually impaired. Which of the following would be most appropriate for the nurse to do when interacting with the client?

Face the client when speaking directly to him.