A&E 3 Exam 1 - test banks

The client with dementia states to the nurse, "I know you. You are Margaret, the girl who lives down the street from me." Which response by the nurse is most therapeutic? A: Mrs. Jones, I am Rachel, a nurse here at the hospital. B: Now Mrs. Jones, you know who I am. C: Mrs. Jones, I told you already, I'm Rachel and I don't live down the street. D: I think that you forgot that I'm Rachel, Mrs. Jones.

A: Mrs. Jones, I am Rachel, a nurse here at the hospital.

The nurse working in the clinic receives telephone calls from several patients who want appointments as soon as possible. Which patient should be seen first? a. 71-yr-old who has noticed increasing loss of peripheral vision. b. 74-yr-old who has difficulty seeing well enough to drive at night. c. 60-yr-old who is reporting dry eyes with decreased tear formation. d. 64-yr-old who states that it is becoming difficult to read news print.

Answer: a. 71-yr-old who has noticed increasing loss of peripheral vision. Rationale: Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbyopia, decreased tear formation, and impaired night vision.

An older patient reports having "no energy" and feeling increasingly weak. The patient has lost 12 pounds over the past year. Which action should the nurse take initially? a. Ask the patient about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Describe normal changes associated with aging. d. Discuss long-term care placement with the patient.

Answer: a. Ask the patient about daily dietary intake Rationale: In a frail older patient, nutrition is frequently compromised, and the nurse's initial action should be to assess the patient's nutritional status. Active range of motion may be helpful in improving the patient's strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient's assessment data are not consistent with normal changes associated with aging.

A family caregiver tells the home health nurse, "I feel like I can never get away to do anything for myself." Which action by the nurse would directly address this concern? a. Assist the caregiver in finding respite services. b. Assure the caregiver that the work is appreciated. c. Encourage the caregiver to discuss feelings openly with the nurse. d. Tell the caregiver that family members provide excellent patient care.

Answer: a. Assist the caregiver in finding respite services. Rationale: Respite services allow family caregivers to have time away from their caregiving responsibilities. The other actions may also be helpful, but the caregiver's statement clearly indicates the need for some time away

A patient who underwent eye surgery must wear an eye patch until the scheduled postoperative clinic visit. Which patient problem will the nurse address in the plan of care? a. Risk for falls b. Difficulty coping c. Disturbed body image d. Inability to care for home

Answer: a. Risk for falls. Rationale: The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. This increases the risk for falls. There is no evidence in the assessment data for inability to care for home, disturbed body image, or difficulty coping

An alert older patient who takes multiple medications for chronic cardiac and pulmonary diseases lives with a daughter who works during the day. During a clinic visit, the patient tells the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. In planning care for this patient, which problem should the nurse consider as the priority? a. Risk for injury b. Social isolation c. Caregiver strain d. Difficulty coping

Answer: a. Risk for injury Rationale: The patient's age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver strain, or difficulty coping are not physiologic priorities. Drug-drug interactions could cause the most harm to the patient and are therefore the priority.

The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient report frequent "popping" in the ear. c. Clear fluid is visible through the tympanic membrane. d. The patient frequently asks the nurse to repeat information.

Answer: a. The patient has a temperature of 100.6° F. Rationale: The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

The home health nurse visits an older patient with mild forgetfulness. Which new information is of most concern to the nurse in planning care? a. The patient has lost 10 lb (4.5 kg) during the past month. b. The patient tells the nurse that a close friend recently died. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient's son uses a marked pillbox to set up the patient's medications weekly.

Answer: a. The patient has lost 10 lb (4.5 kg) during the past month. Rationale: A 10-pound weight loss may be an indication of depression or elder neglect and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older adult would have friends who have died.

An older adult being admitted is assessed at high risk for falls. Which action should the nurse take first? a. Use a bed alarm system on the patient's bed. b. Administer the prescribed PRN sedative medication. c. Ask the health care provider to order a vest restraint. d. Position the patient in a geriatric recliner with locking tray.

Answer: a. Use a bed alarm system on the patient's bed. Rationale: The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurse's first action should be an alternative such as a bed alarm.

The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would support both the patient's self-management and the goal of medication adherence? a. Use a marked pillbox to set up the patient's medications. b. Discuss the option of moving to an assisted living facility. c. Remind the patient about the importance of taking medications. d. Visit the patient daily to administer the prescribed medications.

Answer: a. Use a marked pillbox to set up the patient's medications. Rationale: Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living or instrumental ADLs.

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for a change in dosage of the eyedrops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eyedrops can be prescribed for you."

Answer: b. "The drops are uncomfortable, but it is important to use them to retain your vision." Rationale: Patients should be taught that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use and do not indicate a need for a dosage or medication change.

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control. b. Administration of corticosteroid drops. c. Need for bed rest for 1 to 2 days after the surgery. d. Importance of coughing and deep breathing exercises.

Answer: b. Administration of corticosteroid drops. Rationale: Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery, and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer. b. Application of a warm compress to a patient's hordeolum. c. Instruction about hand washing for a patient with herpes keratitis. d. Checking for eye irritation in a patient with possible conjunctivitis.

Answer: b. Application of a warm compress to a patient's hordeolum. Rationale: Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

A 75-yr-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Ask the patient about what type of vision problems are being experienced. c. Explain that there are many ways to compensate for decreases in visual acuity. d. Suggest ways of improving the patient's safety, such as using brighter lighting.

Answer: b. Ask the patient about what type of vision problems are being experienced. Rationale: The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment.

The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? a. Have the family select an LTC facility that is relatively new. b. Ask the patient's preference for the choice of an LTC facility. c. Explain the reasons for the need to live in LTC to the patient. d. Request that the patient be placed in a private room at the facility.

Answer: b. Ask the patient's preference for the choice of an LTC facility. Rationale: The stress of relocation is likely to be less when the patient has input into the choice of the facility. The age of the long-term care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and the choice of the facility.

What should the nurse assess to evaluate the effectiveness of bifocal treatment for the patient's myopia and presbyopia? a. Strength of the eye muscles. b. Both near and distant vision. c. Cloudiness in the eye lenses. d. Intraocular pressure changes.

Answer: b. Both near and distant vision. Rationale: Lenses are prescribed to correct the patient's near and distant vision. The nurse may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient's bifocals are effective.

Which action could the registered nurse (RN) who is working in the clinic delegate to a licensed practical/vocational nurse (LPN/VN)? a. Evaluate a patient's ability to administer eyedrops. b. Check a patient's visual acuity using a Snellen chart. c. Inspect a patient's external ear for signs of irritation caused by a hearing aid. d. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D.

Answer: b. Check a patient's visual acuity using a Snellen chart. Rationale: Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice.

A patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Keep the volume low on the hearing aids for the first week. b. Experiment with volume and hearing in a quiet environment. c. Add the second hearing aid after making adjustments to the first hearing aid. d. Begin wearing the hearing aids for an hour a day, gradually increasing the use.

Answer: b. Experiment with volume and hearing in a quiet environment. Rationale: Initially the patient should use the hearing aids in a quiet environment such as the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

Answer: b. Fill the irrigation syringe with body-temperature solution. Rationale: Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe.

The occupational health nurse is caring for an employee who reporting bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take? a. Apply cool compresses. b. Flush the eyes with saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

Answer: b. Flush the eyes with saline. Rationale: In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available. No other interventions should delay flushing the eyes.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV. b. Mannitol (Osmitrol) 100 mg IV. c. Betaxolol (Betoptic) 1 drop in each eye. d. Acetazolamide (Diamox) 250 mg orally.

Answer: b. Mannitol (Osmitrol) 100 mg IV. Rationale: The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered.

How should the nurse evaluate a patient for improvement after treatment of primary open-angle glaucoma (POAG)? a. Question the patient about blurred vision. b. Note any changes in the patient's visual field. c. Ask the patient to rate the pain using a 0 to 10 scale. d. Assess the patient's depth perception when climbing stairs.

Answer: b. Note any changes in the patient's visual field. Rationale: POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

Which patient arriving at the urgent care center will the nurse assess first? a. Patient who is reporting that the left eyelid has just started to droop. b. Patient with acute right eye pain that began while using power tools. c. Patient with purulent left eye discharge and conjunctival inflammation. d. Patient who has redness, crusting, and swelling along the lower right lid margin.

Answer: b. Patient with acute right eye pain that began while using power tools. Rationale: The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss.

The nurse is admitting an acutely ill, older patient to the hospital. Which action should the nurse take? a. Speak slowly and loudly while facing the patient. b. Perform a physical assessment before interviewing the patient. c. Ask a family member to go home and retrieve the patient's cane. d. Begin care by obtaining a detailed medical history from the patient.

Answer: b. Perform a physical assessment before interviewing the patient. Rationale: When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records. After the initial physical assessment to determine the patient's current condition, then the nurse could ask someone to obtain any assistive devices for the patient if applicable.

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which action requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

Answer: b. The nurse encourages the patient to cough. Rationale: Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

Which method should the nurse use to obtain a complete assessment of an older patient? a. Review the patient's health record for previous assessments. b. Use a geriatric assessment instrument to evaluate the patient. c. Ask the patient to write down medical problems and medications. d. Interview both the patient and the primary caregiver for the patient.

Answer: b. Use a geriatric assessment instrument to evaluate the patient. Rationale: The most complete information about the patient will be obtained by using an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment.

What should the nurse include when teaching a patient who has undergone a left tympanoplasty? a. "Remain on bed rest." b. "Keep your head elevated." c. "Avoid blowing your nose." d. "Irrigate your left ear canal."

Answer: c. "Avoid blowing your nose." Rationale: Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

Which statement, if made by an older adult patient, would be of most concern to the nurse in planning care? a. "I prefer to manage my life without much help from other people." b. "I take three different medications for my heart and joint problems." c. "I don't go on daily walks anymore since I had pneumonia 3 months ago." d. "I set up my medications in a marked pillbox so I don't forget to take them."

Answer: c. "I don't go on daily walks anymore since I had pneumonia 3 months ago." Rationale: Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Self-management is appropriate for independently living older adults. On average, an older adult takes seven different medications so the use of three medications is not unusual for this patient. The use of memory devices to assist with safe medication administration is recommended for older adults.

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."

Answer: c. "I will clean the ear canal daily with a cotton-tipped applicator." Rationale: Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful.

Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a. Teach the patient to have all prescriptions filled at the same pharmacy. b. Make a schedule for the patient as a reminder of when to take each medication. c. Ask the patient to bring all medications, supplements, and herbs to each appointment. d. Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements.

Answer: c. Ask the patient to bring all medications, supplements, and herbs to each appointment. Rationale: The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy. Use of supplements and herbal medications need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the patient take medications as scheduled but will not prevent drug-drug interactions.

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) reporting shortness of breath and severe eye pain. Which action will the nurse take first? a. Assess cranial nerve functions. b. Administer the prescribed analgesic. c. Check the patient's oxygen saturation. d. Examine the eye for evidence of trauma.

Answer: c. Check the patient's oxygen saturation. Rationale: ABCS ALWAYS FIRST The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is reporting shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.

Which intervention should the nurse implement to provide optimal care for an older patient who is hospitalized with pneumonia? a. Use a standardized geriatric care plan. b. Plan for transfer to a long-term care facility. c. Consider the preadmission functional abilities. d. Minimize physical activity during hospitalization.

Answer: c. Consider the preadmission functional abilities. Rationale: The plan of care for older adults should be individualized and based on the patient's current functional abilities. A standardized geriatric care plan will not address individual patient needs and strengths. A patient's need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient's needs? a. Suggest that the patient move closer to health care providers. b. Obtain extra medications for the patient to last for 4 to 6 months. c. Ensure transportation to appointments with the health care provider. d. Assess the patient for chronic diseases that are unique to rural areas.

Answer: c. Ensure transportation to appointments with the health care provider. Rationale: Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by buying large quantities of the medications.

An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? a. Notify an elder protective services agency about possible abuse. b. Make a referral for a home assessment visit by the home health nurse. c. Have the family member stay in the waiting area while the patient is assessed. d. Ask the patient how the injury occurred and observe the family member's reaction.

Answer: c. Have the family member stay in the waiting area while the patient is assessed. Rationale: The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document data before notifying the elder protective services agency.

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol b. Albuterol c. Ibuprofen d. Acetaminophen

Answer: c. Ibuprofen Rationale: Nonsteroidal antiinflammatory drugs are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. What is the nurse's most important action during the initial assessment? a. Obtain more information about the cause of the patient's vision loss. b. Obtain information from the spouse about the patient's special needs. c. Make eye contact with the patient and ask about any need for assistance. d. Perform an evaluation of the patient's visual acuity using a Snellen chart.

Answer: c. Make eye contact with the patient and ask about any need for assistance. Rationale: Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked first about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment.

An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Increase the speaking volume. b. Overenunciate while speaking. c. Speak normally but more slowly. d. Use more facial expressions when talking.

Answer: c. Speak normally but more slowly. Rationale: Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend.

When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a. Mechanism of action of anticoagulant therapy b. Effect of atherosclerosis on cerebral blood vessels c. Symptoms indicating that the patient should contact the health care provider d. Impact of the patient's family history on likelihood of developing a serious stroke

Answer: c. Symptoms indicating that the patient should contact the health care provider. Rationale: One of the priority tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur. The other information may also be included in patient teaching but is not as essential in the patient's self-management of the illness.

The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Plan daily activities based on the individual patient needs and desires. b. Obtain information about food and medication allergies from patients. c. Take blood pressures daily and document in individual patient records. d. Teach family members how to cope with patients who are cognitively impaired.

Answer: c. Take blood pressures daily and document in individual patient records. Rationale: Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse.

A patient in the emergency department reports being struck in the right eye with a fist. Which finding is a priority for the nurse to communicate to the health care provider? a. The patient reports a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The patient reports "a curtain" over part of the visual field. d. The area around the right eye is bruised and tender to the touch.

Answer: c. The patient reports "a curtain" over part of the visual field. Rationale: The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye.

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is important to report to the health care provider before the procedure? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes antihypertensive medications. d. The patient gets nauseated with general anesthesia.

Answer: c. The patient takes antihypertensive medications. Rationale: Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia.

The nurse performs a comprehensive assessment of an older patient who is considering admission to an assisted living facility. Which question is the most important for the nurse to ask? a. "Have you had any recent infections?" b. "How frequently do you see a doctor?" c. "Do you have a history of heart disease?" d. "Are you able to prepare your own meals?"

Answer: d. "Are you able to prepare your own meals?" Rationale: The patient's functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

A patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will use drops to keep my pupils dilated until my appointment." b. "I will need to use brighter lights to read for at least the next week." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

Answer: d. "I will cover up with long-sleeved shirts and pants for the next 5 days." Rationale: The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

Which patient is most likely to need long-term nursing care management? a. 72-yr-old who had a hip replacement after a fall at home b. 64-yr-old who developed sepsis after a ruptured peptic ulcer c. 76-yr-old who had a cholecystectomy and bile duct drainage d. 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

Answer: d. 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg) Rationale: Osteoarthritis and obesity are chronic problems that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management.

To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic? a. Perform tympanometry. b. Schedule otoscopic examinations. c. Administer influenza immunizations. d. Discuss exposure to amplified music.

Answer: d. Discuss exposure to amplified music. Rationale: The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to highly amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients.

A patient who has just relocated to a long-term care facility is exhibiting signs of stress related to the move. Which action should the nurse include in the plan of care? a. Remind the patient that making changes is usually stressful. b. Discuss the reason for the move to the facility with the patient. c. Restrict family visits until the patient is accustomed to the facility. d. Have staff members write notes welcoming the patient to the facility.

Answer: d. Have staff members write notes welcoming the patient to the facility. Rationale: Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patient's stress about the move. Family member visits will decrease the patient's sense of stress about the relocation.

In reviewing a patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. What should the nurse plan to assess? a. Visual acuity. b. Pupil reaction. c. Color perception. d. Peripheral vision.

Answer: d. Peripheral vision Rationale: The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient reports that the vision has not improved. b. The patient requests a prescription refill for next week. c. The patient feels uncomfortable wearing an eye patch. d. The patient reports eye pain rated 5 (on a 0 to 10 scale).

Answer: d. The patient reports eye pain rated 5 (on a 0 to 10 scale). Rationale: Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring.

The nurse in the eye clinic is examining a 67-yr-old patient who says, "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Warn the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

Answer: d. Use an ophthalmoscope to examine the posterior eye chambers. Rationale: Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

Which information will the nurse include for a patient considering a cochlear implant? Cochlear implants: a. are not useful for patients with congenital deafness. b. are most helpful as an early intervention for presbycusis. c. improve hearing in patients with conductive hearing loss. d. require extensive training in order to reach the full benefit.

Answer: d. require extensive training in order to reach the full benefit. Rationale: Extensive rehabilitation is required after cochlear implants for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness

Which of the following is essential when caring for a patient who is experiencing delirium? A: Controlling behavioral symptoms with low dose psychotropics B: Identifying the underlying causative condition or illness C: Manipulating the environment to increase orientation D: Decreasing or discontinuing all previously prescribed medications

B: Identifying the underlying causative condition or illness plug the hole in the boat!

A client has been taking 30 mg of duloxetine hydrochloride (Cymbalta) twice daily for 2 months because of depression and vague aches and pains. While interacting with the nurse, the client discloses a pattern of drinking a 6-pack of beer daily for the past 10 years to help with sleep. What should the nurse do first? A. Refer the client to the dual diagnosis program at the clinic. B. Share the information at the next interdisciplinary treatment conference. C. Report the client's beer consumption to the physician. D. Teach the client relaxation exercises to perform before bedtime.

C. Report the client's beer consumption to the physician.

In reviewing an older patients medical record the nurse notes that the last eye exam revealed an intraocular pressure of 28mm hg. which of these tests should the nurse perform for this patient? Visual acuity pupil reaction color perception peripheral vision

Peripheral vision Rational - increased intraocular pressure is an indicator of glaucoma and peripheral vision decreases normal pressure is 10-21

Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.

T/F Post-op cataract surgery patients usually experience little of no pain

True - if pain is present the provider should be notified

The nurse is assessing a 65-yr-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. "Hold this card and read the print out loud." b. "Cover one eye while reading the wall chart." c. "You'll feel a short burst of air directed at your eyeball." TestBankWorld.org d. "A light will be used to look for a change in your pupils."

a. "Hold this card and read the print out loud." The Jaeger card is used to assess near vision problems and presbyopia in persons older than 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

A 65-yr-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment plan? a. "I take metoprolol (Lopressor) for angina." b. "I take aspirin when I have a sinus headache." c. "I have had frequent episodes of conjunctivitis." d. "I have not had an eye examination for 10 years."

a. "I take metoprolol (Lopressor) for angina." It is important to note whether the patient takes any β-adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-Pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

a. A Tono-Pen will be applied to the surface of the eye. Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-Pen. The other techniques are used in testing for other eye disorders.

Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient? (Select all that apply.) a. Assess for depression. b. Review laboratory results. c. Determine food preferences. d. Inspect teeth and oral mucosa. e. Ask about transportation needs.

a. Assess for depression. b. Review laboratory results. d. Inspect teeth and oral mucosa. e. Ask about transportation needs.

Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? a. OS 20/50; OD 20/40 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

a. OS 20/50; OD 20/40 When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.

A patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

a. The patient was oriented and alert when admitted. The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer's disease (AD), which topic will be most important for the nurse to discuss with the patient? a. Tobacco use b. Family history c. Cholesterol level d. Head injury history

a. Tobacco use Tobacco use is a modifiable risk factor for AD. The patient will not be able to modify the increased risk associated with family history of AD and past head injury. While the total cholesterol is borderline high, the high HDL indicates that no change is needed in cholesterol management.

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to a. stand 20 feet away from the wall chart. b. follow the examiner's finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes.

a. stand 20 feet away from the wall chart. When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements.

During the preoperative assessment of a patient scheduled for a right cataract extraction and intraocular lens implantation, it is important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for presence of a white pupil in the right eye. d. for a history of reactions to general anesthetics.

a. the visual acuity of the patient's left eye. Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics.

The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"

b. "I don't know." Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

b. Having the patient's family member administer the medication Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Have the patient take a mid-morning nap. b. Keep window blinds open during the day. c. Provide hourly orientation to time and place. d. Move the patient to a quiet room in the afternoon.

b. Keep window blinds open during the day. A likely cause of sundowning is a disruption in circadian rhythms, and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

b. Maintain a consistent daily routine for the patient's care. Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past.

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options.

b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. e. Ask the spouse what she knows and has considered about dementia care options. The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first.

The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the priority for the nurse to include in the discharge plan for this patient? a. Teach the patient how to assess and care for the foot infection. b. Refer the patient to social services for assessment of resources. c. Schedule the patient to return to outpatient services for foot care. d. Give the patient written information about shelters and meal sites.Answer:

b. Refer the patient to social services for assessment of resources. Rationale: An interprofessional approach, including social services, is needed when caring for homeless older adults. Even with appropriate teaching, a homeless individual may not be able to maintain adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had a fractured hip repair 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

b. Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

A patient seen in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

b. Schedule the patient for more frequent appointments. Ongoing monitoring is recommended for patients with MCI. MCI does not usually interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for a patient with MCI.

The nurse is performing an eye examination on a 76-yr-old patient. The nurse should refer the patient for a more extensive assessment based on which finding? a. The patient's sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

b. The patient reports persistent photophobia. Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences in assessment and would not be unusual in a 76-yr-old patient.

The nurse should report which assessment finding immediately to the health care provider? a. Cone of light is visible. b. Tympanum is blue-tinged. c. Skin in the ear canal is dry and scaly. d. Cerumen is present in the auditory canal.

b. Tympanum is blue-tinged. A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD is made only after other causes of dementia are ruled out. c. new drugs have been shown to reverse AD deterioration dramatically in some patients. d. brain atrophy detected by magnetic resonance imaging (MRI) would confirm the diagnosis of AD.

b. a diagnosis of AD is made only after other causes of dementia are ruled out. The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD.

The nurse is observing a student who is preparing to perform an ear examination for a 30-yr-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

b. chooses a speculum larger than the ear canal. The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear.

b. report any burning or pain at the IV site. Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

c. "Have you noticed ringing in your ears?" Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

A 72-yr-old patient is brought to the clinic by the patient's spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad right now?" b. "How is your self-image?" c. "What did you eat for lunch?" d. "Where were you were born?"

c. "What did you eat for lunch?" This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

Which action should the nurse take when providing patient teaching to a 76-yr-old patient with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching. d. Wait until family members have left before initiating teaching.

c. Ask for permission to turn off the television before teaching. Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching.

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? a. Check the patient's orientation to time and date. b. Obtain a list of the patient's prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patient's ability to recognize a common object such as a pen.

c. Ask the person to use a clock drawing to indicate a specific time. In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimer's disease but are not part of the Mini-Cog exam.

Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes

c. Blurred vision and light sensitivity

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol taken to prevent angina b. Acetaminophen taken frequently for headaches c. Ibuprofen taken for 20 years to treat osteoarthritis d. Albuterol taken since early childhood to treat asthma

c. Ibuprofen taken for 20 years to treat osteoarthritis Nonsteroidal antiinflammatory drugs are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

Which hospitalized patient will the nurse assign to the room closest to the nurses' station? a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination

c. Patient with new-onset confusion, restlessness, and irritability after surgery This patient's history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses' station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues.

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.

c. Place the patient in a room close to the nurses' station. Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of "why" questions can be frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Ask about a family history of dementia. b. Administer the Mini-Mental Status Exam. c. Use the Confusion Assessment Method tool. d. Obtain a list of the patient's usual medications.

c. Use the Confusion Assessment Method tool. CAM The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patient's room.

c. assess for factors that might be causing discomfort. Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors such as pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

c. choose a place without distracting stimuli. Because over stimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Anti anxiety medications may increase the patient's delirium.

A patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

c. loss of recent and long-term memory. Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

When assessing a patient's consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both pupils. c. shine a light into one eye and observe responses of both pupils. d. instruct the patient to follow a moving object using only the eyes.

c. shine a light into one eye and observe responses of both pupils. The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye and then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

When obtaining a health history from a 49-yr-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."

d. "I can't see as far over to the side." The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast

d. Patient who developed a new cough after eating breakfast A new cough after a meal in a patient with dementia suggests possible aspiration, and the patient should be assessed immediately. The other patients also require assessment and intervention but not as urgently as a patient with possible aspiration or pneumonia.

The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-yr-old patient as shown in the accompanying figure, which action should the nurse take first? a. Check the patient's blood glucose level. b. Take the blood pressure on the left arm. c. Use an irrigating syringe to clean the ear canals. d. Report a vision change to the health care provider.

d. Report a vision change to the health care provider. The sudden change in peripheral vision may indicate an acute problem, such as retinal detachment, that should be treated quickly to preserve vision. The other data about the patient are not indicative of any acute problem. The other actions are also appropriate, but the highest priority for this patient is prevention of blindness.

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medication should the nurse question? a. Morphine sulfate 4 mg IV b. Diazepam (Valium) 5 mg IV c. Betaxolol (Betoptic) 0.25% eyedrops d. Scopolamine patch (Transderm Scop) 1.5 mg

d. Scopolamine patch (Transderm Scop) 1.5 mg Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient.

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain hand-held magnifiers

d. Where to obtain hand-held magnifiers Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living. Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain at the patient's bedside and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

d. assign unlicensed assistive personnel (UAP) to stay with and reorient the patient. The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient's safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient's agitation and disorientation.

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. facing the patient directly when speaking. b. speaking slowly and distinctly to the patient. c. administering both the Rinne and Weber tests. d. encouraging the patient to ambulate independently.

d. encouraging the patient to ambulate independently. Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

The nurse performing an eye examination will document normal findings for accommodation when a. shining a light into the patient's eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved toward the patient's eyes.

d. the pupils constrict while fixating on an object being moved toward the patient's eyes. Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object that is being moved from far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

The safest technique for the nurse to use when assisting a blind patient in ambulating to the bathroom is to a. have the patient place a hand on the nurse's shoulder and guide the patient. b. lead the patient slowly to the bathroom, holding on to the patient by the arm. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient, allowing the patient to hold the nurse's elbow.

d. walk slightly ahead of the patient, allowing the patient to hold the nurse's elbow. When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.

A patient with glaucoma who has been using timolol drops for several days tells the nurse that the eye drops cause eye burning and blurry vision for a short time after administration. which of these is the nurses best response? - you should increase your dose - the drops are uncomfortable but you should still use them - it is possible you might have conjunctivitis please come into the clinic today

it is possible you might have conjunctivitis please come into the clinic today