Exam 4 Eyes, Ears, and Reproductive

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? 1.At the onset of menstruation 2.Every month during ovulation 3.Weekly at the same time of day 4.One week after menstruation begins

4 Rationale: The breast self-examination should be performed regularly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1.Diplopia 2.Eye pain 3.Floating spots 4.Blurred vision

4 Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.

A caloric test is prescribed for a client suspected of having disease of the labyrinth. The nurse should obtain which essential item in preparation for this test? 1.An otoscope 2.A tongue blade 3.An emesis basin 4.An ophthalmoscope

1 Rationale: A caloric test is contraindicated if the client has a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine whether the ear canal contains cerumen, which must be removed before the test. An ophthalmoscope, a tongue blade, and an emesis basin are not essential items.

The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? 1.A tuning fork 2.A stethoscope 3.A tongue blade 4.A reflex hammer

1 Rationale: A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client's forehead or above the upper lip over the teeth. Normally the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in 1 ear, the sound is heard in the other ear. If the client has a conductive hearing loss in 1 ear, the sound is heard in that ear. The items identified in the remaining options are not needed to perform the Weber test.

Betaxolol eye drops have been prescribed for a client with glaucoma. The home health nurse preparing to visit the client develops a plan of care that includes monitoring for the side/adverse effects of this medication by taking which assessment action? 1.Monitoring body weight 2.Assessing the glucose level 3.Assessing peripheral pulses 4.Monitoring body temperature

1 Rationale: This medication is an antiglaucoma medication and a beta-adrenergic blocker. The nurse assesses for evidence of heart failure manifested by dizziness, night cough, peripheral edema, and distended neck veins. Intake greater than output, weight gain, and decreased urine output also may indicate heart failure. Hypotension (manifested as dizziness), nausea, diaphoresis, headache, fatigue, and constipation or diarrhea also are potential systemic effects of the medication. Nursing interventions include monitoring body weight; periodically evaluating blood pressure for hypotension; and assessing the apical or radial pulse for strength, weakness, irregular heart rate, and bradycardia

A client being prepared for a myringotomy asks the nurse about the procedure. The nurse should respond by making which statement? 1."This procedure involves removing a bone from the ear." 2."This procedure will reduce the pressure you feel in your ear and allow fluid to drain." 3."This procedure involves removing the eardrum and inserting a mechanical bone in the ear." 4."This procedure involves removal of middle ear and inserting a ring around the ear bones that will vibrate on sound to promote better hearing."

2 Rationale: A myringotomy is a surgical procedure that allows fluid to drain from the middle ear. A small incision is created in the eardrum (tympanic membrane) to relieve pressure that may be caused by excessive buildup of fluid. A tympanostomy tube is inserted into the eardrum to keep the middle ear aerated and to prevent reaccumulation of fluid. A mastoidectomy, in which the mastoid bone is removed or partially removed, may be recommended to treat chronic otitis media that is resistant to other therapies. The tympanic membrane is a structure needed to transmit sound from the air to the ossicles inside the middle ear and then to the oval window in the fluid-filled cochlea. Thus, it ultimately converts and amplifies vibration in air to vibration in fluid. Therefore, options 1, 3, and 4 are incorrect descriptions.

The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding? 1.Acyclovir 2.Ceftriaxone 3.Azithromycin 4.Penicillin G benzathine

2 Rationale: Treatment for gonorrhea consists of antibiotic therapy, usually with ceftriaxone and doxycycline. Acyclovir is the treatment for genital herpes simplex virus; azithromycin is the treatment for Chlamydia infection, and penicillin G benzathine is the treatment for syphilis.

The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. 1.Multiparity 2.Early menarche 3.Early menopause 4.Family history of breast cancer 5.High-dose radiation exposure to chest 6.Previous cancer of the breast, uterus, or ovaries

2, 4, 5, 6 Rationale: Risk factors for breast cancer include nulliparity or first child born after age 30 years; early menarche; late menopause; family history of breast cancer; high-dose radiation exposure to the chest; and previous cancer of the breast, uterus, or ovaries. In addition, specific inherited mutations in BReast CAncer (BRCA)1 and BRCA2 increase the risk of female breast cancer; these mutations are also associated with an increased risk for ovarian cancer.

The nurse instructs a client in the use of a hearing aid. The nurse should include which instruction? 1.Hearing aids do not require any care. 2.Leave the hearing aid in place while showering. 3.Check the battery to ensure that it is working before use. 4.A water-soluble lubricant is used on the hearing aid before insertion.

3 Rationale: The battery of the hearing aid should be checked before use. The hearing aid should be removed for showering because it should not get excessively wet. It also should be put away in its case at night. It should be cleaned according to the manufacturer's directions, which usually consist of cleaning the ear mold with mild soap and water (avoiding excessive wetness), followed by thorough drying. Lubricants or other solvents are not used on the hearing aid.

The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. How should the nurse respond? Select all that apply. 1."It causes the cessation of menstruation." 2."It is pain that occurs during ovulation." 3."It is the presence of tissue outside the uterus that resembles the endometrium." 4."It is also known as primary dysmenorrhea and causes lower abdominal discomfort." 5."Major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia."

3, 5 Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in both structure and function. Major symptoms include pelvic pain, dysmenorrhea, and dyspareunia (painful intercourse). The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Amenorrhea is the cessation of menstruation for at least 3 cycles or 6 months in a woman who has an established pattern of menstruation. Amenorrhea can be caused by a variety of factors. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods. Primary dysmenorrhea refers to menstrual pain without identified pathology.

The nurse is assigned to care for a client with metastatic breast cancer who is taking tamoxifen citrate. The nurse plans to monitor for which changes in laboratory values for this client? Select all that apply. 1.Increase in lipase level 2.Increase in blood glucose level 3.Increase in serum calcium level 4.Increase in serum potassium level 5.Decrease in low-density lipoprotein levels

3, 5 Rationale: Tamoxifen citrate is an antiestrogen and antineoplastic medication. It may increase the calcium level and lower the low-density lipoprotein levels. Before the initiation of therapy, the complete blood count (CBC), platelet count, and serum calcium levels should be determined. These blood levels should continue to be monitored periodically during therapy. The nurse should monitor for signs of hypercalcemia while the client is taking this medication. These signs include increased urine volume, excessive thirst, nausea, vomiting, constipation, decreased muscle tone, and deep bone or flank pain. Options 1, 2, and 4 are not associated with this medication.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? 1."I will handle the area gently." 2."I will wear loose-fitting clothing." 3."I will avoid the use of deodorants." 4."I will limit sun exposure to 1 hour daily."

4 Rationale: The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? 1.Allowing bathroom privileges only 2.Elevating the head of the bed to 45 degrees 3.Wearing dark glasses to read or watch television 4.Placing an eye patch over the client's affected eye

4 Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client's position is prescribed by the primary health care provider; normally, the prescription is to lie flat.

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1.The right eye is tested, followed by the left eye, and then both eyes are tested. 2.Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3.The client is asked to stand at a distance of 40 ft (12 meters) from the chart and to read the largest line on the chart. 4.The client is asked to stand at a distance of 40 ft (12 meters) from the chart and to read the line that can be read 200 ft (60 meters) away by an individual with unimpaired vision.

1 Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 ft (6 meters) from the chart.

The instructor asks a nursing student to identify the phases of the ovarian cycle. Which phases identified by the nursing student indicate an understanding of the ovarian cycle? Select all that apply. 1.Luteal phase 2.Follicular phase 3.Menstrual phase 4.Ovulatory phase 5.Proliferative phase

1, 2, 4 Rationale: The ovarian cycle consists of 3 phases: follicular, ovulatory, and luteal. The menstrual and proliferative phases are phases of the endometrial cycle.

The nurse is providing discharge instructions to the client being discharged after a fenestration procedure for the treatment of otosclerosis. Which statement made by the client indicates a need for further instruction? 1."I should use a straw to drink liquids for the next 2 to 3 weeks." 2."I need to avoid washing my hair and showering for at least 1 week." 3."I should avoid movements requiring bending over for at least 3 weeks." 4."I should take stool softeners to avoid straining when having a bowel movement."

1 Rationale: After ear surgery, clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, to avoid air travel, and to avoid excessive coughing because these activities will increase pressure within the ear. The client should avoid getting the head wet, washing the hair, or showering for at least 1 week, and avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks. The client also should be instructed to avoid straining when having a bowel movement and should be instructed to take stool softeners as prescribed.

The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? 1.Avoid air travel. 2.Shower daily to prevent infection. 3.Resume all normal activities in 1 week. 4.Drink liquids through a straw for the next 2 to 3 weeks.

1 Rationale: After ear surgery, the client needs to be instructed to avoid air travel, excessive coughing, and drinking through a straw for 2 to 3 weeks. In addition, the client should avoid straining when having a bowel movement and should avoid washing the hair, getting the head wet, or showering for 1 week. The client also needs to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

The nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation? 1.Dizziness 2.Photophobia 3.Hemianopsia 4.Blurred vision

1 Rationale: Ménière's disease is a disorder of the inner ear characterized by dizziness and loss of balance. This requires the addition of safety to the care plan. The clinical manifestations in the remaining options are not found with Ménière's disease.

The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client? 1."You need to perform BSE on the same day every month." 2."It is not necessary to do BSE because you are postmenopausal." 3."You are not at risk for breast cancer because you are in the postmenopausal phase." 4."Mammograms performed every 20 years are sufficient in the postmenopausal phase."

1 Rationale: Women who are in the postmenopausal phase are taught to do BSE on the same day of every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle when the breasts are less tender. It is important for postmenopausal women to do BSE monthly because they can get breast cancer. Mammograms need to be performed more frequently than every 20 years and per American Cancer Association guidelines

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure? 1.Do the exam on the same day every month. 2.Do the exam 7 days after the start of the menstrual cycle. 3.Examine the left breast with the left hand and vice versa. 4.Use the tips of the fingers to increase the likelihood of feeling lumps.

1 Rationale: Women who are postmenopausal are taught to do BSE on the same day every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle, when the breasts are least tender. Each breast is examined with the opposite hand. The pads of the fingers, not the fingertips, should be used for palpation. The client may use a circular, up and down, or wedge method of assessment. Consistency of use of the same method is more important than the actual method used.

The nurse is reviewing a plan of care for a client with cancer of the cervix who is undergoing treatment with a cesium (radiation) implant. Which nursing interventions are most appropriate for this client? Select all that apply. 1.Maintain the client on bed rest. 2.Place the client on a low-fiber diet. 3.Keep the head of the bed flat at all times. 4.Restrict visitors to visiting for 60 minutes per day. 5.Stand at the entrance of the room to communicate with the client when possible.

1, 2, 5 Rationale: During application of the cesium implant, the client is on bed rest. The client may be logrolled from side to side, and the head of the bed may be raised to 45 degrees. The client is given a low-fiber diet to prevent frequent bowel movements, which is a side effect of the radiation. To minimize radiation exposure, the nurse stands at the head of the bed or at the entrance to the room. Visitors are limited to 30 minutes per day in the radiation area.

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. 1.Apply some force when instilling the irrigation solution. 2.Position the client with the affected side down after the irrigation. 3.Warm the irrigating solution to a temperature that is close to body temperature. 4.Position the client to turn the head so that the ear to be irrigated is facing upward. 5.Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.

2, 3, 5 Rationale: During the irrigation, the client is positioned so that the ear to be irrigated is facing downward because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.

The nurse has provided discharge instructions to a client who underwent a right mastectomy with axillary lymph node dissection. Which statement made by the client indicates a need for further instruction regarding home care measures? 1."It is all right to use a straight razor to shave under my arms." 2."I must be sure to use thick potholders when I am cooking." 3."I must be sure not to have blood pressures taken or blood drawn from my right arm." 4."I should inform all of my other health care providers that I have had this surgical procedure."

1 Rationale: After mastectomy with axillary lymph node dissection, the client is at risk for arm edema and infection. The client should be instructed regarding home care measures to prevent these complications. The client should be told to avoid activities such as carrying heavy objects or having blood pressure measurements taken on the affected arm. The client also should be instructed in the techniques to avoid trauma to the affected arm, such as using an electric razor to shave under the arms, using gloves when working in the garden, and using or wearing thick potholders when cooking.

The community health nurse conducts a health promotion program for community members regarding testicular cancer. The nurse determines that further information needs to be provided if a community member states that which is a sign of testicular cancer? 1.Alopecia 2.Back pain 3.Painless testicular swelling 4.Heavy sensation in the scrotum

1 Rationale: Alopecia is not an assessment finding in testicular cancer. Alopecia may occur, however, as a result of radiation or chemotherapy. The remaining options are assessment findings in testicular cancer. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

A client with a history of ovarian cysts is seen by the primary health care provider (PHCP). The client has had 2 previous surgeries related to this condition. Her PHCP recommends an exploratory laparoscopic procedure for the current ovarian cyst, which has persisted for several months. The client states that the prior ovarian cysts were benign and questions the need for this procedure. Which response is bestfor the nurse to provide? 1."A prolonged ovarian abnormality should be evaluated thoroughly." 2."With your recurrent history, one of these times the cyst will be malignant." 3."The surgical procedure is minimal, and you will not have to be concerned after you learn the results." 4."I appreciate your concern regarding another surgical procedure. Would you like to discuss your concerns?"

1 Rationale: An ovarian cyst is considered an abnormal occurrence, and it should be thoroughly evaluated. Not all ovarian cysts are malignant, and this client may never experience a malignancy. Any surgical procedure has some risk and pain associated with it. The nurse cannot promise the procedure will be minimal and that there will be no reason for concern after learning the results. Discussing the concerns does involve therapeutic communication but is not the best response given the situation. In addition, it is nontherapeutic for the nurse to tell the client that he or she appreciates the client's concern.

The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the primary health care provider (PHCP) has prescribed atropine sulfate and pilocarpine hydrochloride eye drops. The nurse should contact the PHCP before the home visit for which reason? 1.Clarify the prescription for the atropine sulfate. 2.Clarify the prescription for the pilocarpine hydrochloride. 3.Determine the date of the scheduled follow-up PHCP visit. 4.Determine the extent of the intraocular pressure caused by the glaucoma.

1 Rationale: Atropine sulfate is a mydriatic and cycloplegic medication that is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and cause increased intraocular pressure in the eye. Pilocarpine hydrochloride is a miotic agent used in the treatment of glaucoma. It is unnecessary to contact the PHCP regarding the date for follow-up treatment. In fact, the client may know this date, which the nurse can ask about during the home care visit. It is unnecessary to know the extent of the intraocular pressure caused by the glaucoma in planning care for the client.

Betaxolol eye drops have been prescribed for a client with glaucoma. The nurse monitoring this client for side/adverse effects of the medication would place highest priority on which assessment? 1.Pulse rate 2.Blood glucose 3.Respiratory rate 4.Oxygen saturation

1 Rationale: Betaxolol is a beta-blocking agent as well as an antiglaucoma medication. Nursing assessments include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. The nurse also assesses for evidence of heart failure as manifested by dizziness, night cough, peripheral edema, and distended neck veins.

The nurse is reviewing the record of a client who was admitted to the hospital with a diagnosis of ovarian cancer. A client has received an unsealed radioactive isotope for treatment of thyroid cancer. Which instruction is essentialfor the nurse to provide the client? 1."Flush the toilet at least 3 times after use." 2."Increase intake of fruits with a core, such as apples and pears." 3."Avoid contact with pregnant women, infants, and children for 3 months." 4."Use disposable eating utensils, plates, and cups for the next 6 months."

1 Rationale: Bodily fluids contain the radioactive material, so others should be shielded from possible exposure. Clients should at best have a dedicated toilet for use during the first 2 weeks and should also flush 3 times after use. Some radioactivity will be in the saliva for about the first week, so during this time fruits with cores that will become contaminated should be avoided. Disposable eating utensils should also be used during this period of time. Contact with pregnant women, infants, and children is avoided for the first week and then a distance of 3 feet (1 meter) or more should be maintained and exposure should be limited to 1 hour per day.

Capecitabine has been prescribed for a client with breast cancer, and the client asks the nurse about the side effects of the medication. The nurse responds that a frequent side effect of this medication is which finding? 1.Diarrhea 2.Weakness 3.Irritability 4.Increased appetite

1 Rationale: Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Frequent side effects include diarrhea, nausea, vomiting, stomatitis, hand and foot syndrome (painful palmar-plantar erythema and swelling with paresthesias, tingling, and blistering), fatigue, anorexia, and dermatitis. Weakness, irritability, and increased appetite are not side effects of this medication.

A client with testicular cancer is receiving cisplatin. The nurse assesses for which finding as a toxic effect of this medication? 1.Tinnitus 2.Diarrhea 3.Nausea and vomiting 4.Elevated white blood cell (WBC) count

1 Rationale: Cisplatin is a medication that kills cells primarily by forming cross-links between and within strands of deoxyribonucleic acid (DNA). Its principal use is in the treatment of testicular cancer, although it also can be used to treat carcinomas of the ovary, bladder, head, and neck. It can cause neurotoxicity, nephrotoxicity, bone marrow depression, and ototoxicity, which manifests as tinnitus and high-frequency hearing loss. Nausea and vomiting are expected side effects, which can be severe and begin 1 hour after administration, persisting for 1 to 2 days. Diarrhea is not an associated side effect or toxic effect.

A client who has been diagnosed with breast cancer is to receive chemotherapy with both cisplatin and vincristine. The client asks the nurse why both medications must be given together. The nurse should explain to the client that the combination of 2 chemotherapeutic medications is used for which reason? 1.Increase the destruction of tumor cells. 2.Prevent the destruction of normal cells. 3.Decrease the risk of the alopecia and stomatitis. 4.Increase the likelihood of erythrocyte and leukocyte recovery.

1 Rationale: Cisplatin is an alkylatinglike medication, and vincristine is a vinca alkaloid. Alkylating medications are cell-cycle nonspecific. Vinca alkaloids are cell-cycle specific and act on the M phase. Single-agent medication therapy seldom is used. Combinations of medications are used to increase the destruction of tumor cells.

A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? 1."Have you had any vaginal discharge?" 2."Do you have any blood in your urine?" 3."Have you had any flank pain or headaches?" 4."Have you noticed any swelling in your feet?"

1 Rationale: Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick white vaginal discharge. Hematuria, edema, flank pain, and headache are clinical manifestations associated with urinary tract infections.

A client who is scheduled for cataract surgery requires preoperative instillation of cyclopentolate eye drops as prescribed. The client asks the nurse why this medication is needed, and the nurse provides education. Which statement by the client indicates that teaching has been effective? 1."The medication dilates the pupil of the operative eye." 2."The medication constricts the pupil of the operative eye." 3."The medication is needed for the initiation of miosis in the operative eye." 4."The medication provides the necessary lubrication to the nonoperative eye."

1 Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication that is used preoperatively to dilate the eye. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. The statements in the other options are incorrect.

A female client with a diagnosis of breast cancer is taking cyclophosphamide. The client calls the health care clinic and tells the nurse that the medication is upsetting her stomach. Which instruction should the nurse provide to the client? 1.Take the medication with food. 2.Avoid drinking fluids while taking the medication. 3.Try to take the medication with a small amount of orange juice. 4.Continue to take the medication on an empty stomach, and lie down after taking the medication.

1 Rationale: Hemorrhagic cystitis is a toxic effect that can occur with the use of this medication. The medication should be taken on an empty stomach, but if the client complains of gastrointestinal (GI) upset, it can be taken with food. The client who is taking cyclophosphamide needs to be instructed to drink copious amounts of fluids during the administration of this medication. Orange juice probably would cause and increase the GI upset. Option 4 will not assist in relieving the discomfort experienced by the client.

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1.Cardiovascular disease 2.Frequent urinary tract infections 3.A history of migraine headaches 4.Frequent upper respiratory infections

1 Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 2, 3, and 4 do not identify risk factors associated with this eye disorder

The nurse transcribes a medication prescription for ifosfamide for a client with a diagnosis of germ cell cancer of the testes. The nurse reviews the client's history and looks for another prescription for which medication, which usually is administered with the antineoplastic medication? 1.Mesna 2.Melphalan 3.Prednisone 4.Bleomycin sulfate

1 Rationale: Ifosfamide is used to treat refractory germ cell cancer of the testes. Concurrent therapy with mesna and at least 2 L of oral or intravenous fluid daily will limit the toxicity of this medication, evidenced by bone marrow depression and hemorrhagic cystitis. Mesna is a detoxifying agent used to inhibit the hemorrhagic cystitis induced by ifosfamide. The medications in options 2, 3, and 4 are not routinely administered with ifosfamide.

A client is admitted to the nursing unit after undergoing radical prostatectomy for cancer. The nurse anticipates that which problem would be of most concern to the client in the immediate postoperative period? 1.Concern about the outcome of surgery 2.Continuous pain because of the effects of cancer 3.Appearance disturbance as a result of the presence of a suprapubic catheter 4.Concern about caring for self at home because of insufficient help after discharge

1 Rationale: In the immediate postoperative period, the client who has had surgery for cancer may experience fear or concern related to the uncertain outcome of surgery. Postoperative pain is classified as acute, not continuous. The client may experience an alteration in appearance, but this is more likely to be related to the anticipated change in sexual function than the presence of the suprapubic catheter. The priority focus in the immediate postoperative period is not on concerns that apply to hospital discharge.

The nurse creates a plan of care for a client with a diagnosis of Ménière's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on which item? 1.Measures that will ensure safety 2.Determining any knowledge deficits 3.Assessing for any psychosocial needs 4.Asking the client about knowledge of the treatment plan

1 Rationale: Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan for the hospitalized client with Ménière's disease should be safety issues to prevent falls or injury. Although client knowledge and psychosocial needs may be components of the plan of care, safety is the priority issue.

The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? 1.Safety measures 2.Self-care measures 3.Food items to avoid 4.Knowledge about medication therapy

1 Rationale: Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan should focus on safety issues to prevent falls or injury to the client. Although self-care measures, dietary therapy, and medication therapy may be components of the plan of care, safety is the priority issue.

The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted? 1.The client looks at the surgical site. 2.The client performs the prescribed arm exercises. 3.The client takes the pain medication as prescribed. 4.The client has read all of the postoperative materials provided by the hospital nurse.

1 Rationale: Of the options provided, the client behavior in the correct option demonstrates the greatest adaptation or adjustment (looking at the surgical site). This indicates that the client has acknowledged and is beginning to cope with the loss of the breast. Reading postoperative care booklets and performing prescribed exercises indicate an interest in self-care and are positive signs indicating adjustment. Taking pain medication is not related to adjustment to the loss of the breast.

The nurse is doing preoperative teaching with a client newly diagnosed with a stage I cervical cancer. Which statement by the client indicates that education was effective? 1."I have carcinoma that is just in the cervix." 2."My carcinoma has extended to the pelvis and the vagina." 3."I have carcinoma that has extended beyond the cervix but has not extended to the pelvic wall." 4."My carcinoma has extended beyond the true pelvis and has involved the bladder or rectal mucosa."

1 Rationale: Stage I carcinoma is strictly confined to the cervix. In stage II, the carcinoma has extended beyond the cervix but has not extended to the pelvic wall. Stage III carcinoma has extended to the pelvic wall at the lower third of the vagina, and stage IV carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum.

The nurse is caring for a client on the oncology unit who has developed stomatitis during chemotherapy for treatment of breast cancer. The nurse should plan which measure to treat this complication? 1.Rinse the mouth with diluted baking soda or saline. 2.Use lemon and glycerin swabs liberally on painful oral lesions. 3.Brush the teeth and use non-waxed dental floss at least twice a day. 4.Place the client on NPO (nothing by mouth) status for 12 hours, and then resume liquids.

1 Rationale: Stomatitis, or mouth ulcerations, occurs with the administration of many antineoplastic medications. The client's mouth should be examined daily for signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with baking soda or saline. Lemon and glycerin swabs may cause pain and further irritation. The client should avoid brushing the teeth and flossing when stomatitis is severe. Food and fluids are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet. Instruct the client to avoid spicy foods and foods with hard crusts or edges.

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? 1."The hearing aid should not be worn if an ear infection is present." 2."The ear mold for the hearing aid should be washed with mild soap and water once a month." 3."The hearing aid should be removed from the ear at the end of the day and then turned off after removal." 4."The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."

1 Rationale: The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use, and the client should keep extra batteries on hand at all times.

The client is preparing for discharge from the hospital after radical vulvectomy. The nurse should include which activity as appropriate for the client immediately after discharge? 1.Walking 2.Driving a car 3.Sexual activity 4.Sitting for lengthy periods

1 Rationale: The client should resume activity slowly, but walking is a beneficial activity. The client should know to rest when fatigued. Sexual activity is prohibited for 4 to 6 weeks after surgery. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged standing or sitting.

The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client? 1.Avoid frequent douching. 2.Undergarments made of nylon are best. 3.Intrauterine devices are a good birth control method. 4.It is necessary to change sanitary pads only every 8 hours.

1 Rationale: The client who has been diagnosed with PID should avoid frequent douching because it decreases the natural flora that controls the growth of infectious organisms. The client should wear cotton undergarments, and clothes should not fit tightly. Intrauterine devices increase the client's susceptibility to infection. Sanitary pads should be changed at least every 4 hours. Tampons should not be used during the acute infection, and some primary health care providers may recommend avoiding them indefinitely. The client also should avoid strong soaps, sprays, powders, and similar products that will irritate the perineum.

The clinic nurse has provided instructions regarding home care measures to a female client diagnosed with pelvic inflammatory disease (PID). Which statement, if made by the client, indicates an understanding of these measures? 1."I need to avoid tight-fitting clothing." 2."I need to douche once in the morning and once in the evening." 3."I need to see a primary health care provider to get an intrauterine device for birth control." 4."I need to wear tampons instead of sanitary pads when I have my menstrual period."

1 Rationale: The client who has been diagnosed with PID should avoid frequent douching because this decreases the normal flora that controls the growth of infectious organisms. The client should wear cotton undergarments, and clothes should not fit tightly. Tampons, if worn, should be changed frequently but should not be used during an acute infection. In fact, many primary health care providers recommend avoiding the use of tampons indefinitely. Intrauterine devices increase the client's susceptibility to PID.

A cervical radiation implant is placed in a client who is undergoing treatment of cervical cancer. The nurse should initiate which activity prescription as the most appropriate for this client? 1.Bed rest 2.Out of bed ad lib 3.Out of bed in a chair only 4.Ambulation to the bathroom only

1 Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. The nurse avoids turning the client on the side. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled.

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? 1.Elevated on a pillow 2.Level with the right atrium 3.Dependent to the right atrium 4.Elevated above shoulder level

1 Rationale: The client's operative arm should be positioned so that it is elevated on a pillow and not exceeding shoulder elevation. This position promotes optimal drainage from the limb, without impairing the circulation to the arm. If the arm is positioned flat (option 2) or dependent (option 3), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1.After a shower or bath 2.While standing to void 3.After having a bowel movement 4.While lying in bed before arising

1 Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE.

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? 1.Left shoulder 2.Right scapula 3.Right shoulder 4.Small of the back

1 Rationale: The nurse should instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the left breast is to be examined, the pillow would be placed under the left shoulder; therefore, all other options are incorrect.

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination? 1.Pull the pinna up and back before inserting the speculum. 2.Pull the earlobe down and back before inserting the speculum. 3.Tilt the client's head forward and down before inserting the speculum. 4.Use the smallest speculum available to decrease the discomfort of the exam.

1 Rationale: The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back, and the nurse visualizes the external canal while slowly inserting the speculum. The remaining options are incorrect procedures.

A woman has just been told by the primary health care provider that she has breast cancer. The woman responds, "Oh, no! Does this mean I'm going to die?" The nurse interprets the woman's initial reaction as which response? 1.Fear 2.Rage 3.Denial 4.Anxiety

1 Rationale: The woman's reaction is one of fear. The woman has verbalized the object of fear (dying), which makes anxiety incorrect. There is no evidence of rage or denial in the woman's statement.

The nurse is taking a history from a client suspected of having testicular cancer. Which data will be most helpful in determining the risk factors for this type of cancer? 1.Age and race 2.Marital status 3.Number of children 4.Number of sexual partners

1 Rationale: Two basic but important risk factors for testicular cancer are age and race. The disease occurs most frequently in white males, generally between the ages of 15 and 34 years. Other risk factors include a history of undescended testis and a family history of testicular cancer. Marital status and number of children are not associated with increased risk of testicular cancer. In addition, the number of sexual partners is not associated with testicular cancer

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1.The right eye is tested, followed by the left eye, and then both eyes are tested. 2.Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

1 Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 feet (6 meters) from the chart.

The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply. 1.A blood test will confirm the diagnosis. 2.Syphilis signs and symptoms are divided into stages. 3.Syphilis can be spread through vaginal, anal, or oral sex. 4.Having syphilis once provides lifelong immunity from repeat infection. 5.Syphilis will always be present in a chronic state, as there is no cure for this illness.

1, 2, 3 Rationale: Syphilis can be cured with the initiation of prompt treatment. A blood test can confirm this diagnosis. Syphilis is staged in relation to signs and symptoms and the length of the infection. Syphilis may be transmitted via vaginal, anal, or oral sex. An individual may be positive for syphilis more than once. Syphilis can be cured by early treatment.

A preadolescent client asks the nurse about the onset of puberty. The nurse describes which changes as indicating puberty? Select all that apply. 1.Mood swings occur. 2.Pubic hair will develop. 3.Breast development begins. 4.Uterus matures to adult size. 5.Height will increase due to a growth spurt.

1, 2, 3, 5 Rationale: During puberty, a number of body changes will occur. These changes include mood swings, the beginning development of pubic hair, breast bud development, and growth spurt. The uterus does not reach full maturity until approximately 17 years of age.

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication to treat breast cancer. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. 1.Stop the infusion. 2.Prepare to apply ice or heat to the site. 3.Notify the primary health care provider (PHCP). 4.Restart the IV at a distal part of the same vein. 5.Prepare to administer a prescribed antidote into the site. 6.Increase the flow rate of the solution to flush the skin and subcutaneous tissue.

1, 2, 3, 5 Rationale: Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the IV administration of an antineoplastic medication, the infusion is stopped and the PHCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.

The community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cervical cancer. Which are risk factors for cervical cancer? Select all that apply. 1.Smoking 2.Multiple sex partners 3.Human papillomavirus infection 4.Annual gynecological examinations 5.First intercourse before 17 years of age

1, 2, 3, 5 Rationale: Risk factors for cervical cancer include human papillomavirus infection, active and passive cigarette smoking, and certain high-risk sexual activities (first intercourse before 17 years of age, multiple sex partners, and male partners with multiple sex partners). Screening via regular gynecological examinations and Papanicolaou (Pap) tests with treatment of precancerous abnormalities decreases the incidence and mortality of cervical cancer.

A client who is receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply. 1.Avoid contact sports. 2.Wash hands frequently. 3.Increase intake of fresh fruits and vegetables. 4.Avoid crowded places such as shopping malls. 5.Treat a sore throat with over-the-counter products. 6.Avoid people who have received live attenuated vaccines.

1, 2, 4, 6 Rationale: Effective measures should be used to protect the client from infection and bleeding. A variety of interventions are essential to keep the client who is receiving chemotherapy safe. Live attenuated vaccines can easily infect clients with myelosuppression, and crowded places usually have people who are sick and coughing and sneezing, which can easily cause illness in myelosuppressed clients. Contact sports can result in injury or bleeding, and hand washing is the mainstay of asepsis and protection from infection. The client with myelosuppression should not eat fresh fruits and vegetables because of the risk of contamination or infection. All foods should be thoroughly cooked. Option 5 is incorrect because many over-the-counter products contain acetaminophen or aspirin, which could potentially mask an elevated temperature. Additionally, aspirin is an antiplatelet and can cause bleeding. Clients receiving chemotherapy should not take any other medications without direction from the primary health care provider.

A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply. 1.Yawning 2.Humming 3.Swallowing 4.Chewing gum 5.Sucking on hard candy

1, 3, 4, 5 Rationale: Clients who are prone to barotrauma should perform any of a variety of mouth movements to equalize pressure between the ear and the atmosphere, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because the resulting lack of pressure change in the ear will contribute to pressure buildup behind the tympanic membrane. Humming does not affect pressure.

A client with a medical diagnosis of breast cancer is undergoing chemotherapy. The client complains to the nurse about losing her hair and severe fatigue from the treatment. Which interventions should the nurse implement for this client? Select all that apply. 1.Review side effects of chemotherapy and treatment with the client. 2.Teach the client how to resolve specific concerns of her personal life. 3.Teach the client to pace activities with rest so as to maintain strength. 4.Offer information on available counseling services and support groups. 5.Tell the client about some other clients who have had breast cancer treatment. 6.Inquire how the cancer diagnosis and treatment affect the client's normal routine.

1, 3, 4, 6 Rationale: It is not therapeutic nor is it the nurse's role to teach the client how to resolve specific concerns of her personal life. The nurse should determine how the cancer diagnosis and treatment are affecting the client's normal routine, and the client should be aware of potential side effects of treatment so as to cope with the events with medications or other measures. It is important for the nurse to inform clients about support groups available (e.g., Reach for Recovery) so the client does not feel isolated. Teaching clients to pace activities even when they feel well will conserve energy so they ultimately feel stronger and less fatigued. It is a breach of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) laws for the nurse to discuss other clients and their medical problems

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1.Avoid activities that require bending over. 2.Contact the surgeon if eye scratchiness occurs. 3.Take acetaminophen for minor eye discomfort. 4.Expect episodes of sudden severe pain in the eye. 5.Place an eye shield on the surgical eye at bedtime. 6.Contact the surgeon if a decrease in visual acuity occurs.

1, 3, 5, 6 Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon, because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.

The nurse is performing an assessment on a client who asks how she might recognize when she is ovulating. The nurse should explain that which occurs at ovulation? Select all that apply. 1.Breast tenderness 2.Decreased sex drive 3.Small amount of vaginal spotting 4.Slight decrease in basal body temperature 5.Lower abdominal pain known as Mittelschmerz 6.Presence of spinnbarkeit-thin and clear mucous discharge

1, 3, 5, 6 Rationale: While ovulation predictors may be individual in nature, the most common predictors are breast tenderness, increase in libido, small amount of vaginal bleeding, slight elevation in basal body temperature, the presence of Mittelschmerz (middle pain), and spinnbarkeit.

A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply. 1."Some forms of HPV can lead to cervical cancer." 2."You cannot get HPV if you have had only 1 sex partner." 3."There are no vaccinations available to protect against HPV." 4."HPV is most commonly spread during vaginal or anal sexual contact." 5."In some types, HPV will go away on its own and does not cause health issues."

1, 4, 5 Rationale: HPV has now become the most common sexually transmitted infection. Some types of HPV have been found to have a strong link to cervical cancer, while other types of HPV may resolve without any intervention. HPV may be contracted with any sexual partner. There is a vaccine for the known strains that may lead to cervical cancer, which can be administered to females from ages 9 to 26 years. HPV is spread through vaginal or anal sexual contact.

The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? 1.Strict bed rest 2.A myringotomy 3.A mastoidectomy 4.Diphenhydramine

2 Rationale: A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear and may be necessary to treat acute otitis media. Strict bed rest is not necessary, although activity may be restricted. Additionally, bed rest would not assist in reducing pressure or allowing fluid to drain. In some recurrent and persistent cases, the mastoid bone is removed or partially removed for chronic otitis media. Benadryl is an antihistamine with antiemetic properties.

The client with breast cancer has been given a prescription for cyclophosphamide. The nurse determines that the client understands the proper use of the medication if the client states to take which measure? 1.Increase dietary intake of potassium. 2.Increase fluid intake to 2 to 3 L/day. 3.Take the medication with large meals. 4.Decrease dietary intake of magnesium.

2 Rationale: An adverse effect of cyclophosphamide is hemorrhagic cystitis. The client should drink large amounts of fluid during the administration of this medication. Clients also should observe for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be encouraged to increase potassium intake. The client would not be instructed to alter magnesium intake.

A client has been prescribed betaxolol eye drops for the treatment of glaucoma. The ambulatory care nurse determines that the client understands proper medication use if the client states the need to return to the office for monitoring of what item(s)? 1.Hearing acuity 2.Blood pressure 3.Blood glucose level 4.Presence of calf pain

2 Rationale: Betaxolol is an antiglaucoma medication and a beta-adrenergic blocker. Systemic effects of this medication are hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea. The client should have the blood pressure monitored for hypotension and the pulse assessed for strength, weakness, irregular rate, and bradycardia. Bowel activity and evidence of heart failure also should be assessed. The other options are incorrect and not associated with this medication.

The community health nurse is preparing an educational session for a group of women and will be discussing the primary prevention strategies and treatment measures for breast cancer. What information should the nurse include in the educational session? 1.Older women are more likely to get mammograms. 2.Treatment decisions are based on a woman's overall health. 3.Women younger than age 65 are more likely to get breast cancer. 4.A woman's age is the main factor used to decide which screening methods to use.

2 Rationale: Breast cancer occurs most often in women who are 65 years of age or older, and older women are less likely to have mammograms. Rather than using the woman's age to decide on screening and treatment measures, the woman's overall health is used to make these determinations, since health status has a greater influence on tolerance to treatment.

Capecitabine has been prescribed for a client with breast cancer, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further instruction? 1."I need to monitor my temperature." 2."I need to be sure to go to the clinic to receive my yearly flu vaccine." 3."I may have some diarrhea, but if it becomes severe, I will call my health care provider." 4."It's important for me to contact my primary health care provider if I have any fever or other signs of infection."

2 Rationale: Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Adverse effects include bone marrow depression, cardiovascular toxicity, and respiratory toxicity. The client is instructed to obtain primary health care provider (PHCP) approval before receiving immunizations because the medication lowers the body's resistance to infection. Diarrhea is a frequent side effect of this medication, but the client should contact the PHCP if it becomes severe. The client should monitor his or her temperature and call the PHCP for severe diarrhea or for a fever or other sign of infection.

The nurse is counseling a woman about decreasing her risk for cervical cancer. Which statement by the client indicates a need for further counseling? 1."I need to seek prompt treatment for vaginitis." 2."Condoms are needed only if I do not trust a new partner." 3."A partner who is uncircumcised will present an increased risk." 4."I need to keep appointments for Pap tests at the frequency advised by my primary health care provider."

2 Rationale: Condoms should be used for adequate protection, especially with new partners. Sexually transmitted infections (which could be acquired without condom use) increase the client's risk of cervical cancer. Uncircumcised partners may present an increased risk. The woman should adhere to guidelines for early detection of cervical cancer (by Pap test) and should seek prompt treatment of vaginitis and cervicitis if they occur.

Which statement made by a client who will undergo cytoreductive (debulking) surgery for ovarian cancer indicates that teaching by the nurse was effective? 1."The surgery will remove precancerous tissue." 2."The surgery will help to reduce the size of the tumor." 3."The surgery will cure the cancer by removing all gross and microscopic tumor cells." 4."The surgery is focused at improving the appearance of the previously treated body part.

2 Rationale: Cytoreductive or debulking surgery may be used if a large tumor cannot be removed completely, as is often the case with late-stage ovarian cancer (e.g., the tumor is attached to a vital organ or has spread throughout the abdomen). When this occurs, as much tumor as possible is removed, and adjuvant chemotherapy or radiation may be prescribed. Therefore, the remaining options are incorrect purposes for cytoreductive surgery.

The nurse is reviewing the primary health care provider's prescriptions for a client with Ménière's disease. Which diet would mostlikely be prescribed for the client? 1.Low-fat diet 2.Low-sodium diet 3.Low-cholesterol diet 4.Low-carbohydrate diet

2 Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for a client with Ménière's disease. The diets in the remaining options are not specific to the client with Ménière's disease.

A client with chronic glaucoma is being started on medication therapy with acetazolamide. The nurse teaches the client that which can occur early with the use of this medication? 1.Fatigue 2.Diuresis 3.Headache 4.Loss of libido

2 Rationale: Diuresis is an early side effect of acetazolamide that usually subsides with continued treatment. This is because the medication is also a weak diuretic, although it is no longer prescribed for that purpose. Fatigue, headache, and loss of libido are common side effects of therapy, but these may not subside spontaneously.

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? 1.Placing cool compresses on the affected arm 2.Elevating the affected arm on a pillow above heart level 3.Avoiding arm exercises in the immediate postoperative period 4.Maintaining an intravenous site below the antecubital area on the affected side

2 Rationale: Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring.

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action? 1.Take the medication with food. 2.Increase fluid intake to 2000 to 3000 mL daily. 3.Decrease sodium intake while taking the medication. 4.Increase potassium intake while taking the medication.

2 Rationale: Hemorrhagic cystitis is an adverse effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be told to increase potassium intake. The client would not be instructed to alter sodium intake

A client arrives at the emergency department stating that a mosquito flew into his ear and that he is hearing a constant buzzing noise. Which intervention should the nurse take first? 1.Initiate a consult for an ear specialist. 2.Look into the ear canal using a flashlight. 3.Irrigate the ear and try to drown the mosquito. 4.Use an ear forcep and try to pull the mosquito out.

2 Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Therefore, the first action would be to look into the ear canal using a flashlight. Substances such as viscous lidocaine may be prescribed to be instilled into the ear to suffocate the insect, which then is removed with the use of ear forceps. Irrigation may be necessary to flush the ear canal once the mosquito is killed, but this would not be the first action.

A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? 1.Irrigation of the ear 2.Instillation of mineral oil 3.Instillation of antibiotic eardrops 4.Instillation of corticosteroid ointment

2 Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction. Antibiotic eye drops and corticosteroid ointment are not initial nursing actions.

The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likelyto report which symptom during an acute attack? 1.Fatigue 2.Tinnitus 3.Headache 4.Insomnia

2 Rationale: Ménière's disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus. Fatigue, headaches, and insomnia are not associated with this disorder.

The nurse is observing an assistive personnel (AP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed? 1.The AP is speaking directly to the client. 2.The AP overenunciates words when speaking. 3.The AP faces the client when speaking to the client. 4.The AP touches the client's arm to gain his or her attention.

2 Rationale: Overenunciating words does not make lip reading easier and is demeaning to the deaf person. It is best to speak in a normal manner. The actions in the remaining options are appropriate communication strategies for the client who is deaf.

The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1.Client report of blurred vision 2.Client report of "tunnel vision" 3.Client report of ocular erythema 4.Client report of halos around lights

2 Rationale: POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.

The nurse is providing discharge instructions to a client who has undergone treatment of cervical cancer with a radiation (cesium) implant. Which instruction should the nurse provide to the client? 1.Avoid douching for at least 1 year. 2.Use a vaginal dilator 3 times a week. 3.Sexual activity can be resumed in about 2 months. 4.Bed rest is recommended for at least 1 week after discharge.

2 Rationale: Radiation causes scarring and fibrosis of the vagina, with a decrease in normal vaginal secretions. The client is instructed to use a vaginal dilator to prevent vaginal narrowing and stenosis. A vaginal discharge often occurs, and the woman may need to douche twice daily for as long as the discharge and odor persist. Sexual activity after internal radiation treatment can be resumed in about 3 weeks. Bed rest is not required.

The clinic nurse has conducted a health screening clinic to identify clients who are at risk for cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at lowest risk for developing this type of cancer? 1.A multiparity client 2.A single white client 3.A client with a history of chronic cervicitis 4.A client who had early, frequent intercourse with multiple sexual partners

2 Rationale: Risk factors associated with cervical cancer include early, frequent intercourse with multiple sexual partners; multiparity; chronic cervicitis; and a history of genital herpes or human papilloma. Cervical cancer also occurs with higher frequency in African Americans. Regarding the options provided, the single white client is at lowest risk for the development of cervical cancer.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? 1."Have you ever had surgery?" 2."Do you plan to have any other children?" 3."Do either of you have diabetes mellitus?" 4."Do either of you have problems with high blood pressure?"

2 Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility, because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.

The nurse has provided instructions to a client regarding testicular self-examination (TSE). Which client statement indicates the need for further teaching regarding TSE? 1."I know to report any small lumps." 2."I examine myself every 2 months." 3."I examine myself after I take a warm shower." 4."I feel a hard and cord-like thing in back and going up."

2 Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding (option 4) is normal. After a warm bath or shower, the scrotum is relaxed, making it easier to perform TSE.

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? 1.Glucose level 2.Calcium level 3.Potassium level 4.Prothrombin time

2 Rationale: Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium level should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1.Test the corneal reflexes. 2.Test the 6 cardinal positions of gaze. 3.Test visual acuity, using a Snellen eye chart. 4.Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

2 Rationale: Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1.Test the corneal reflexes. 2.Test the 6 cardinal positions of gaze. 3.Test visual acuity, using a Snellen eye chart. 4.Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

2 Rationale: Testing the 6 cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with both eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? 1.To examine the testicles while lying down 2.That the best time for the examination is after a shower 3.To gently feel the testicle with one finger to feel for a growth 4.That TSEs should be done at least every 6 months

2 Rationale: The TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

A client is experiencing blockage of the eustachian tubes. The nurse educates the client on how the client may forcibly open the eustachian tube. Which statement by the client indicates that the teaching has been effective? 1."I should tap the side of the head lightly." 2."I should perform the Valsalva maneuver." 3."I should use cotton-tipped applicators in the ears." 4."I should chew food using exaggerated mouth movements."

2 Rationale: The Valsalva maneuver is performed through forced exhalation against a closed airway. Performing the Valsalva maneuver increases pressure in the nasopharynx and may help open a blocked eustachian tube. The actions described in the other options will not accomplish this.

A 27-year-old client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask her whether the breast lumps seem to become more prominent or troublesome at which time? 1.After menses 2.Before menses 3.During menses 4.At any time, regardless of the menstrual cycle

2 Rationale: The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Therefore, the other options are incorrect.

A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1.Increase sodium in the diet. 2.Avoid sudden head movements. 3.Lie still and watch the television. 4.Increase fluid intake to 3000 mL a day.

2 Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? 1."How often do you have sexual relations?" 2."Please share with me more about your concerns." 3."You are still young and have nothing to be concerned about." 4."You should not have a decline in testosterone until you are in your 80s."

2 Rationale: The nurse needs to establish trust when discussing sexual relationships with men. The nurse should open the conversation with broad statements to determine the true nature of the client's concerns. The frequency of intercourse is not a relevant first question to establish trust. Testosterone declines with the aging process.

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? 1.Focus on a close object. 2.Focus on a distant object. 3.Close 1 eye and read letters on a chart. 4.Raise 1 finger when the sound is heard.

2 Rationale: The nurse tests for accommodation by initially asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object, such as a finger held about 3 in (7.5 cm) from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes.

The student nurse is working with a registered nurse (RN) in the clinic. The RN is educating the student nurse on dysfunction in the area of the semicircular canals of the ear. Which statement by the student nurse indicates that the teaching has been effective? 1."Tinnitus is common." 2."Disturbance in balance occurs." 3."Conduction hearing loss often happens." 4."Sensorineural hearing loss is not unusual."

2 Rationale: The semicircular canals function to aid the client's sense of balance. These canals do not relate to hearing function or the presence of tinnitus.

A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear? 1.Pruritus 2.Tinnitus 3.Hearing loss 4.Burning in the ear

2 Rationale: Tinnitus is the most common complaint of clients with otological problems, especially problems involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with problems of the inner ear.

The nurse has given a client who is at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states that the medication is taken at what time before the triggering event? 1.At least 2 days before 2.At least 1 hour before 3.At least the day before 4.At least a half-day before

2 Rationale: To be maximally effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate, scopolamine, promethazine, and prochlorperazine. The time frames in the remaining options are incorrect.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1.Apply normal saline drops. 2.Note the time of day the test was done. 3.Contact the primary health care provider (PHCP). 4.Instruct the client to sleep with the head of the bed flat.

2 Rationale: Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the PHCP as an initial action. Flat positions may increase the pressure

The ambulatory care nurse is providing discharge instructions to a female client who underwent cryosurgery with laser therapy because of a positive Papanicolaou test. Which statement by the client indicates an understanding of the instructions? 1."I should take sitz baths every 4 hours for the next week." 2."I should expect the vaginal discharge to be clear and watery." 3."Very strong pain medications will be needed to relieve any discomfort I may have." 4."If I note any odor to the vaginal discharge, I should call the primary health care provider immediately."

2 Rationale: Vaginal discharge should be clear and watery after cryosurgery with laser therapy. The client should be told that the vaginal discharge may be odorous as a result of the sloughing of dead cell debris. This vaginal odor takes about 8 weeks to resolve. The client should be instructed to avoid any sitz baths or tub baths while the area is healing, which takes approximately 10 weeks. Pain is mild after this procedure, and very strong pain medication will not be needed.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1.Provide the client with materials on legal blindness. 2.Instruct the client that he or she may need glasses when driving. 3.Inform the client of where he or she can purchase a white cane with a red tip. 4.Inform the client that it is best to sit near the back of the room when attending lectures.

2 Rationale: Vision that is 20/20 is normal-that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1.Provide the client with materials on legal blindness. 2.Instruct the client that he or she may need glasses when driving. 3.Inform the client of where he or she can purchase a white cane with a red tip. 4.Inform the client that it is best to sit near the back of the room when attending lectures.

2 Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness.

The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the procedure. Which statement by the client indicates that the teaching has been effective? 1."Stand 10 ft (3 meters) from the chart and cover 1 eye." 2."Stand 20 ft (6 meters) from the chart and cover 1 eye." 3."Stand 30 ft (9 meters) from the chart and read the largest line on the chart." 4."Stand 40 ft (12 meters) from the chart and read the largest line on the chart."

2 Rationale: Visual acuity is assessed in 1 eye at a time and then in both eyes together, with the client comfortably standing or seated. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 ft (6 meters) from the chart. The right eye is tested first with the left eye covered; then the left eye is tested with the right eye covered; and then both are tested together.

The community health nurse is preparing an educational class on ovarian cancer for a group of women. Which signs and symptoms should the nurse include in the presentation? Select all that apply. 1.Feeling hungry all the time 2.Having urinary urgency or frequency 3.Experiencing pelvic or abdominal swelling 4.Sense of feeling that something is "falling out" 5.Developing a macular-papular rash over the abdomen

2, 3 Rationale: Signs and symptoms of ovarian cancer are often very subtle. Urinary urgency or frequency, abdominal or pelvic pain or swelling, vague gastrointestinal disturbances such as dyspepsia or gas, and unexplained weight loss are potential signs and symptoms and require further investigation. Hunger and a rash are not associated with this condition. A sense of something "falling out" may be reported by the client experiencing uterine prolapse.

The nurse employed in a fertility clinic is providing information to a couple considering in vitro fertilization. The nurse's explanation should most appropriately include which information? Select all that apply. 1.Embryo transfer occurs through an abdominal incision. 2.A fertilized ovum is transferred into the woman's uterus. 3.Mild spotting or cramping may occur following egg removal. 4.A medication protocol for follicle development will be prescribed. 5.Ova and sperm are collected and immediately transferred into the woman's uterus.

2, 3, 4 Rationale: In vitro fertilization is a method of medically assisted reproduction for women with nonpatent, diseased, or missing fallopian tubes or with infertility of unknown cause. Ova and sperm are obtained from potential parents or donors, placed in a nutrient medium, and allowed to incubate for approximately 18 hours; then the fertilized ovum is transferred into the woman's uterus via vaginal catheter insertion. The woman houses the pregnancy throughout gestation and gives birth. No abdominal incision is made during this procedure. Mild spotting or cramping may occur following egg removal. A medication protocol including daily injectable gonadotropins for follicle development will be prescribed.

The nursing student is asked to discuss information related to the uterus with female high school students. Which statements by the nursing student are accurate? Select all that apply. 1."The uterus consists mostly of skeletal muscle." 2."The uterus is a pelvic organ when not pregnant." 3."The uterus weighs approximately 2.2 lb (1000 g) at term pregnancy." 4."The uterus weighs approximately 2 oz (60 g) in the nonpregnant state." 5."The uterus is composed of 3 layers: endometrium, myometrium, and perimetrium."

2, 3, 4, 5 Rationale: Before conception, the uterus is a small, pear-shaped cavity contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 2 oz (60 g) and has a capacity of about ⅓ oz (10 mL). At the end of pregnancy, the uterus weighs approximately 2.2 lb (1000 g) and has sufficient capacity for the fetus, placenta, and amniotic fluid. The uterus mostly consists of smooth muscle and is composed of 3 layers. The innermost layer is the endometrium, the middle layer is the myometrium, and the outer layer is the perimetrium.

The nurse should include which intervention in the care of a client who has undergone a vaginal hysterectomy for the treatment of cancer? Select all that apply. 1.Elevate the knee gatch on the bed. 2.Encourage ambulation as prescribed. 3.Remove antiembolism stockings twice daily. 4.Assist with range-of-motion (ROM) leg exercises. 5.Check placement of pneumatic compression boots.

2, 3, 4, 5 Rationale: The client is at risk for deep vein thrombosis (DVT) or thrombophlebitis after this surgery, as with any other major surgery. The nurse should avoid using the knee gatch in the bed because doing so inhibits venous return, thus placing the client at greater risk for DVT or thrombophlebitis. The nurse will implement measures that prevent DVT or thrombophlebitis; ROM exercises, ambulation, antiembolism stockings, and pneumatic compression boots are all helpful.

The nurse is interviewing a middle-aged woman with a history of fibrocystic disorder of the breasts. Which statements made by the client indicate a need for further teaching? Select all that apply. 1."I might experience pain in my underarm region." 2."My symptoms will decrease just before menstruation." 3."After I experience menopause, my symptoms may lessen." 4."Taking oral contraceptives now will increase my symptoms." 5."Upon self-breast examination, I may detect lumpiness in the upper, outer area of my breasts."

2, 4 Rationale: The nurse assesses the client with fibrocystic breast disorder for worsening symptoms (breast lumps, painful breasts extending into the underarm region, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormonal changes. Taking oral contraceptive pills and experiencing menopause may also help to decrease the signs and symptoms of fibrocystic disease.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1.A defect in the cochlea 2.A defect in cranial nerve VIII 3.A physical obstruction to the transmission of sound waves 4.A defect in the sensory fibers that lead to the cerebral cortex

3 Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.

The nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation? 1.Sitting near loud music is not harmful. 2.Prolonged ringing in the ears after loud noises is normal. 3.Cup the hands over the ears if loud noise is expected suddenly. 4.Ear plugs or other protectors are necessary only with the use of power tools.

3 Rationale: A variety of ear-protective devices are available commercially. These include disposable and reusable plugs, headbands, and foam-filled muffs. They should be used around any type of loud noise, such as from power tools, machinery, lawn mowers, chain saws, or other equipment. Sitting near loud music should be avoided whenever possible. If a loud noise is suddenly anticipated, the ears should be covered for protection. The client should see a primary health care provider for tinnitus or hearing loss after exposure to a loud noise.

A client with glaucoma is receiving acetazolamide. The nurse educator provides education to a group of nurses about the indications for and effect of this medication. Which statement by one of the nurses indicates that the teaching has been effective? 1."This works to prevent hypertension." 2."This works to prevent hyperthermia." 3."This works to decrease intraocular pressure." 4."This works to maintain an adequate blood pressure for cerebral perfusion."

3 Rationale: Acetazolamide is a carbonic-anhydrase inhibitor used to treat glaucoma. The medication decreases the formation of aqueous humor. The statements in the remaining options are not indicative of the purpose of this medication.

The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? 1.A client with bilateral profound hearing loss 2.A client who communicates primarily by speech 3.A client who became deaf before learning to speak 4.A client who received no benefit from conventional hearing aids

3 Rationale: Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use of speech as the primary mode of communication, lack of benefit from conventional hearing aids, evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure.

The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? 1.Maintain a supine position. 2.Change the ear dressing daily. 3.Monitor for signs of facial nerve injury. 4.Position the client on the affected side to promote drainage.

3 Rationale: After mastoidectomy, the nurse should assess for signs of facial nerve injury (cranial nerve VII), such as facial drooping. The nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also should monitor for signs of pain, dizziness, or nausea. The client should be instructed to lie on the unaffected side to prevent disruption of the surgical site. The head of the bed should be elevated at least 30 degrees. The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively.

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication to treat breast cancer. When implementing the plan, the nurse should make which statement to the client? 1."You can take aspirin as needed for headache." 2."You can drink beverages containing alcohol in moderate amounts each evening." 3."You need to consult with the primary health care provider (PHCP) before receiving immunizations." 4."It is fine to receive a flu vaccine at the local health fair without PHCP approval because the flu is so contagious."

3 Rationale: Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without the PHCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects.

Capecitabine has been prescribed for a client with breast cancer. The nurse should tell the client that which blood test will be done periodically while the client is taking this medication? 1.Liver function tests 2.Bilirubin level assay 3.Complete blood count (CBC) 4.Triglyceride level determination

3 Rationale: Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Bone marrow depression can occur from the use of this medication, and a CBC and blood chemistry studies should be done periodically. Liver function tests, bilirubin level assay, and triglyceride levels are unnecessary.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 9:00 a.m. for surgery that is scheduled for 9:15 a.m. What initial action should the nurse take in relation to the characteristics of the medication action? 1.Provide lubrication to the operative eye prior to giving the eye drops. 2.Call the surgeon, as this medication will further constrict the operative pupil. 3.Consult the surgeon, as there is not sufficient time for the dilative effects to occur. 4.Give the medication as prescribed; the surgeon needs optimal constriction of the pupil.

3 Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis, not pupil constriction. The nurse should consult with the surgeon about the time of administration of the eye drops, because 15 minutes is not adequate time for dilation to occur.

The preoperative medication sheet identifies that cyclopentolate is prescribed for a client before cataract surgery. The client asks the nurse what the medication is for, and the nurse provides education. Which statement by the client indicates that teaching has been effective? 1."It lubricates the eye." 2."It makes my pupils smaller." 3."It paralyzes the muscles in my eye." 4."It causes my vessels to become smaller."

3 Rationale: Cyclopentolate is used for preoperative mydriasis. It is a rapid-acting mydriatic and cycloplegic medication. Cycloplegics are medications that paralyze the ciliary muscle, and mydriatics are medications that dilate the pupil. Cyclopentolate becomes effective in 25 to 75 minutes, and the effects last for 6 to 24 hours. The statements in the remaining options are not actions of this medication.

A community health nurse is providing an educational session on cancer of the cervix for women living in the community. The nurse informs the community residents that which is an early sign of this type of cancer? 1.Abdominal pain 2.Constant and profuse bleeding 3.Irregular vaginal bleeding or spotting 4.Dark and foul-smelling vaginal drainage

3 Rationale: Early cancer of the cervix usually is asymptomatic. The 2 chief symptoms are leukorrhea (vaginal discharge) and irregular vaginal bleeding or spotting. The vaginal discharge increases gradually in amount and becomes watery and finally dark and foul-smelling because of necrosis and infection of the tumor mass. As the disease progresses, the bleeding may become constant and may increase in amount.

An adolescent seen in the health care clinic has been diagnosed with endometriosis. The client asks the clinic nurse to describe this condition. Which response should the nurse provide? 1."It always causes infertility." 2."It causes the cessation of menstruation." 3."It is the presence of tissue outside the uterus." 4."It is also known as primary dysmenorrhea."

3 Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in both structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Endometriosis can lead to pelvic scarring, pain, and possible infertility. Amenorrhea is the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation and can be due to a variety of causes. Primary dysmenorrhea refers to menstrual pain without identified pathology.

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client? 1.A wider than normal ear canal 2.A pearly gray tympanic membrane 3.Redness and swelling in the ear canal 4.An excessive amount of cerumen lodged in the ear canal

3 Rationale: External otitis is a painful condition caused when irritating or infective agents come into contact with the skin of the external ear. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal narrows the canal and can lead to temporary hearing loss from obstruction. The tympanic membrane is not usually affected in external otitis. Cerumen does not cause external otitis; however, external otitis can result if the person uses a sharp or small object that traumatized the external ear when trying to remove the cerumen.

The nurse is providing instructions to the client who is receiving external radiation therapy. Which statement, if made by the client, indicates the need for further instruction? 1."I will dry affected areas with patting motions." 2."I will wear soft clothing over the affected site." 3."I will use a washcloth to wash the affected area." 4."I need to make sure I carry my purse on the unaffected side."

3 Rationale: External radiation therapy requires that markings be placed on the skin so that therapy can be aimed at the affected areas. The hand rather than a washcloth should be used to wash the area to avoid irritation. The nurse should instruct the client who is undergoing external radiation therapy to dry affected areas with a patting (rather than rubbing) motion so as not to disrupt the markings on the skin. Soft clothing should be worn so that the affected area is not irritated. The client should be sure to carry her purse on the unaffected side.

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? 1.Complaints of ringing in the ear 2.An excessive amount of cerumen in the ear canal 3.Intolerance for sound levels that do not bother other people 4.Complaints of dizziness and sensations of being "off balance"

3 Rationale: Hyperacusis is a change in hearing for a client and the intolerance for sound levels that do not bother other people. Ringing in the ears is known as tinnitus. An excessive amount of cerumen in the ear canal is not associated with hyperacusis. Complaints of dizziness and sensations of being "off balance" are known as vertigo.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? 1.Assessing for edema 2.Monitoring temperature 3.Monitoring blood pressure 4.Assessing blood glucose level

3 Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side and adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 2, and 4 are not specifically associated with this medication.

The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? 1.Speak loudly to the client to facilitate hearing. 2.Speak directly into the impaired ear to facilitate hearing. 3.Speak in a normal tone and face the client when speaking. 4.Speak frequently to the client to provide sensory stimulation.

3 Rationale: Measures that facilitate hearing in the client with a hearing impairment include speaking in a normal tone, avoiding shouting, talking directly to the client while facing the client, and speaking clearly. If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided.

A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? 1."The medication will help dilate the eye to prevent pressure from occurring." 2."The medication will relax the muscles of the eyes and prevent blurred vision." 3."The medication causes the pupil to constrict and will lower the pressure in the eye." 4."The medication will help block the responses that are sent to the muscles in the eye

3 Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? 1."The medication will help dilate the eye to prevent pressure from occurring." 2."The medication will relax the muscles of the eyes and prevent blurred vision." 3."The medication causes the pupil to constrict and will lower the pressure in the eye." 4."The medication will help block the responses that are sent to the muscles in the eye."

3 Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

The nurse in the primary health care provider's office is performing a postoperative assessment of a client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should provide which information to the client about her complaint? 1.These sensations are signs of a complication. 2.These sensations probably will be permanent. 3.These sensations dissipate over several months and usually resolve after 1 year. 4.It is nothing to worry about because most women who have this type of surgery experience this problem.

3 Rationale: Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in most women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve by 1 year after surgery. These sensations are not a sign of a complication and are not permanent. The nurse would not tell the client that a complaint is nothing to worry about because this is nontherapeutic and avoids the client's concern.

A client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse should ask about which risk factor related to infection of the ears? 1.Occupational noise 2.Exposure to loud noise 3.Congenital abnormalities 4.Use of drilling and other power tools

3 Rationale: Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockages of the eustachian tube. Risk factors include young age (usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. The remaining options are risk factors for hearing loss. Hearing loss can occur as a result of an acute loud noise (acoustic trauma) or as a result of chronic exposure to loud noise (noise-induced hearing loss).

The client has a regular 32-day cycle. She asks on which day she most likely ovulates. How should the nurse reply? 1.Day 14 2.Day 16 3.Day 18 4.Day 20

3 Rationale: Ovulation typically occurs 14 days prior to day 1 of the next menstrual cycle. Subtracting 14 days from 32 results in day 18 being the most likely time of ovulation.

A client calls the ambulatory care clinic and tells the nurse that she found an area that looks like the peel of an orange when performing breast self-examination (BSE) but found no other changes. What is the nurse's best response to this client? 1."Good job performing your BSE. I am sure that is nothing to be concerned about." 2."Make sure you tell the primary health care provider about your finding at the next regularly scheduled visit." 3."I am glad you called to report this finding. Can you come to the clinic to see your primary health care provider tomorrow?" 4."Do you have a thermometer? You need to take your temperature and call back if you have a fever over 101º F (38.3º C)."

3 Rationale: Peau d'orange or orange peel appearance of the skin over the breast is associated with late breast cancer. Therefore, the nurse would arrange for the client to come to the clinic as soon as possible. Peau d'orange is not indicative of an infection.

The nurse working in a long-term care facility notes that several clients are taking pilocarpine hydrochloride eye drops. The nurse ensures that which medication is available on the nursing unit for use if a client should develop systemic toxicity from pilocarpine hydrochloride 1.Disulfiram 2.Cyclopentolate 3.Atropine sulfate 4.Naloxone hydrochloride

3 Rationale: Pilocarpine hydrochloride is a cholinergic agent. Atropine sulfate must be available in the event of systemic toxicity from pilocarpine hydrochloride. Pilocarpine toxicity is manifested by vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Disulfiram is an alcohol deterrent used in the management of alcoholism in selected clients. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication used preoperatively for surgical procedures on the eye. Naloxone hydrochloride is an opioid antagonist used to reverse opioid-induced respiratory depression.

The nursing student is assigned to care for a client with glaucoma for whom pilocarpine hydrochloride eye drops have been prescribed. The nursing instructor asks the student to describe the action of the eye medication. Which statement by the student indicates an understanding of the purpose of this medication? 1."The medication prevents blurred vision by relaxing the muscles of the eyes." 2."The medication dilates the eye to prevent increased pressure from occurring." 3."The medication increases the blood flow to the retina and also will lower the pressure in the eye." 4."The medication blocks responses that are sent to the brain that direct the actions of the muscles in the eye."

3 Rationale: Pilocarpine hydrochloride is a miotic that is used to lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. The statements in the remaining options are incorrect.

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1.Speak loudly but mumble or slur the words. 2.Speak loudly and clearly while facing the client. 3.Speak at normal tone and pitch, slowly and clearly. 4.Speak loudly and directly into the client's affected ear.

3 Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1.Speak loudly. 2.Speak frequently. 3.Speak at a normal volume. 4.Speak directly into the impaired ear.

3 Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

Pilocarpine hydrochloride is prescribed for a client with glaucoma. The nurse checks the medication supply room to ensure that atropine sulfate is available for administration in the event that systemic toxicity occurs from the use of pilocarpine hydrochloride. The nurse also monitors for which sign of systemic toxicity? 1.Flushing 2.Anorexia 3.Bradycardia 4.Hypertension

3 Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity, manifested as vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate is the antidote for systemic reactions that occur with pilocarpine. Flushing and anorexia are not specifically associated with this medication.

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? 1."TSE is performed once a month." 2."TSE should be performed on the same day each month." 3."It is best to do TSE first thing in the morning before a bath or shower." 4."The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand."

3 Rationale: TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand. It is best to perform the exam during or after (not before) a warm shower or bath when the scrotum is most relaxed.

The nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which assessment question would assist in eliciting the most specific data regarding the cause of this syndrome? 1."Did you start your menses at an early age?" 2."Have your menstrual periods been irregular?" 3."Do you use tampons during your menstrual period?" 4."Have you been consuming a high intake of green leafy vegetables?"

3 Rationale: TSS is caused by infection and is often associated with tampon use. Disseminated intravascular coagulation is a complication of TSS. Options 1, 2, and 4 are unrelated to the etiology of TSS.

Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement? 1."This medication can be used only to treat breast cancer." 2."Yes, your family member can take this medication for bladder cancer as well." 3."This medication can be taken to prevent and treat clients with breast cancer." 4."This medication can be taken by anyone with cancer as long as their health care provider approves it.

3 Rationale: Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy and for preventing breast cancer in those that are at high risk.

Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement? 1."This medication can be used only to treat breast cancer." 2."Yes, your family member can take this medication for bladder cancer as well." 3."This medication can be taken to prevent and treat clients with breast cancer." 4."This medication can be taken by anyone with cancer as long as their primary health care provider approves it."

3 Rationale: Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy and for preventing breast cancer in those that are at high risk.

The client reports to the nurse that while performing testicular self-examination, he found a lump the size and shape of a pea. Which statement is the most appropriate response to the client? 1."Lumps like that are normal. Don't worry." 2."Let me know if it gets bigger next month." 3."That's important to report even though it might not be serious." 4."That could be cancer. I'll ask the primary health care provider to examine you."

3 Rationale: Testicular cancer almost always occurs in only 1 testicle and is usually a pea-size, painless lump when discovered. The cancer is highly curable if found early. The finding should be reported to the primary health care provider.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1.Avoid overuse of the eyes. 2.Decrease the amount of salt in the diet. 3.Eye medications will need to be administered for life. 4.Decrease fluid intake to control the intraocular pressure.

3 Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of her or his life. Options 1, 2, and 4 are not accurate instructions.

The home health care nurse is providing instructions to a client after a vulvectomy. Which instruction should the nurse provide to the client? 1."You can engage in sexual activity in 2 weeks." 2."It is all right to begin to drive a car as long as you do not drive long distances." 3."Resume activities slowly, keeping in mind that walking is a beneficial activity." 4."It is important to rest and sit in a chair with your legs elevated as much as possible."

3 Rationale: The client should resume activities slowly, and walking is a beneficial activity. Sexual activity is prohibited for approximately 4 to 6 weeks after surgery. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged sitting and standing. The client should not be instructed to sit in a chair as much as possible because pressure on the surgical site could lead to complications related to the surgery.

The nurse is caring for a client with cancer of the prostate who has undergone a prostatectomy. Which action should the nurse include in discharge instructions? 1.Avoid driving the car for a few days. 2.Restrict fluid intake to prevent incontinence. 3.Avoid lifting objects heavier than 20 lb (9 kg) for at least 6 weeks. 4.Notify the primary health care provider if small blood clots are noticed during urination.

3 Rationale: The client who has undergone a prostatectomy should avoid lifting objects heavier than 20 lb (9 kg) for at least 6 weeks. Driving a car and sitting for long periods are restricted for at least 3 weeks. A high daily fluid intake should be maintained to limit clot formation and prevent infection. Small pieces of tissue or blood clots may be passed during urination for up to 2 weeks after surgery; this is an expected occurrence.

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test? 1."I will tell you when I see the colored dots." 2."I will tell you when I see the flash of bright light." 3."I will tell you when the small object is in my visual field." 4."I will tell you when the blocks and shapes are in my visual field."

3 Rationale: The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner approximately 2 ft (60 cm) away. The eyes of the client and the examiner should be at the same level. Both the examiner and the client cover the eyes directly opposite to one another and stare at each other's uncovered eye. A small object is brought in from the peripheral visual field, and the superior, temporal, inferior, and nasal fields are evaluated. The client states when he or she sees the object.

The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. The nurse should teach the client to put the pillow in which location for self-examination of the right breast? 1.Under the left scapula 2.Under the left shoulder 3.Under the right shoulder 4.Under the small of the back

3 Rationale: The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the right breast is to be examined, the pillow would be placed under the right shoulder and vice versa. Therefore, options 1, 2, and 4 are incorrect.

The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is needed when the client makes which statement? 1."I will cleanse my ear mold." 2."I will try reinserting the hearing aid." 3."I will raise the volume of my hearing aid." 4."I will make sure that my hair is not caught between the ear mold and canal."

3 Rationale: To reduce or eliminate whistling from a hearing aid, it should be reinserted, making certain that no hair is caught between the ear mold and canal. The ear mold or ear can be cleansed, and lowering the volume of the aid might help.

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? 1."You have normal vision." 2."You have some degree of blindness." 3."You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." 4."You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."

3 Rationale: When recording visual acuity as measured by the Snellen chart, the nurse would record the numerical fraction noted at the end of the last line successfully read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/30 means that the client can read at a distance of 20 ft (6 meters) what a client with normal vision can read at 30 ft (9 meters). Normal visual acuity is 20/20. Legal blindness is defined as the best corrected vision in the better eye of 20/200 or less.

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1.Total loss of vision 2.Pain in the affected eye 3.A yellow discoloration of the sclera 4.A sense of a curtain falling across the field of vision

4 Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this problem. A retinal detachment is an ophthalmic emergency, and even more so if visual acuity is still normal.

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the primary health care provider's prescriptions, expecting which type of eye drops to be prescribed? 1.A miotic agent 2.A thiazide diuretic 3.An osmotic diuretic 4.A mydriatic medication

4 Rationale: A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the client with a cataract. These medications act by dilating the pupils; they also constrict blood vessels. A miotic medication constricts the pupil. An osmotic diuretic may be used to decrease intraocular pressure. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

The clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which finding should the nurse expect to observe if the eardrum is perforated? 1.A red and bulging eardrum 2.Dense white patches on the eardrum 3.A colony of black dots on the eardrum 4.A round or oval darkened area on the eardrum

4 Rationale: A round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. A red and bulging eardrum is indicative of acute purulent otitis media. Dense white patches are seen on the eardrum of a client with sequelae of repeated ear infections. A colony of black dots on the eardrum suggests a yeast or fungal infection.

Which statement made by the client who had ear surgery to treat otosclerosis would indicate that the client understands postoperative home care instructions? 1."It is okay to take a shower and wash my hair." 2."I can resume my tennis lessons starting next week." 3."I should drink liquids through a straw for the next 2 to 3 weeks." 4."I will take stool softeners as prescribed by my primary health care provider."

4 Rationale: After ear surgery, the client needs to avoid straining when having a bowel movement. The client needs to be instructed to avoid drinking with a straw, air travel, and excessive coughing for 2 to 3 weeks. The client needs to avoid getting the head wet, washing the hair, and showering for 1 week and to avoid rapid movements of the head, bouncing, and bending over for 3 weeks.

The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate? 1.Document the finding. 2.Reinforce the dressing. 3.Mark the site and continue to monitor. 4.Contact the primary health care provider (PHCP).

4 Rationale: After enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the PHCP needs to be notified immediately. The remaining options are not appropriate nursing actions for this client.

A female client with carcinoma of the breast is admitted to the hospital for treatment with intravenously administered doxorubicin. The client tells the nurse that she has been told by her friends that she is going to lose all her hair. What is the most appropriate nursing response? 1."Your friends are correct." 2."You will not lose your hair." 3."Hair loss may occur, but it will grow back just as it is now." 4."Hair loss may occur, and it will grow back, but it may have a different color or texture."

4 Rationale: Alopecia (hair loss) can occur after the administration of many antineoplastic medications. Alopecia is reversible, but the new hair growth may have a different color and texture. Therefore, options 1, 2, and 3 are incorrect.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1.Cranial nerve I, olfactory 2.Cranial nerve IV, trochlear 3.Cranial nerve III, oculomotor 4.Cranial nerve VII, facial nerve

4 Rationale: An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made, because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.

A client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication? 1.Diarrhea 2.Hair loss 3.Chest pain 4.Peripheral neuropathy

4 Rationale: An adverse effect specific to vincristine is peripheral neuropathy, which occurs in almost every client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation rather than diarrhea is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all antineoplastic medications. Chest pain is unrelated to this medication.

The primary health care provider (PHCP) writes a prescription for capecitabine for a client with breast cancer who was admitted to the hospital. The nurse should contact the PHCP to verify the prescription if which condition is noted in the assessment data? 1.Myalgia 2.Psoriasis 3.Rheumatoid arthritis 4.Chronic kidney disease

4 Rationale: Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. A contraindication to the use of this medication is severe renal impairment such as that which occurs in chronic kidney disease. Myalgia, psoriasis, and rheumatoid arthritis are not contraindications to this medication.

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? 1.Diarrhea 2.Hypermenorrhea 3.Abnormal bleeding 4.Abdominal distention

4 Rationale: Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? 1."I need to restrict my carbohydrate intake." 2."I need to drink at least 3 L of fluid per day." 3."I need to maintain a low-fat and low-cholesterol diet." 4."I need to be sure to consume foods that are low in sodium."

4 Rationale: Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease.

The nurse is caring for a client diagnosed with breast cancer receiving combination chemotherapy. Which nursing intervention is the most appropriate? 1.Give 2 agents from the same medication class. 2.Give 2 agents with like nadirs at the same time. 3.Test the client's knowledge about each agent's nadir. 4.Avoid giving agents with the same nadirs and toxicities at the same time.

4 Rationale: Each chemotherapeutic agent has a specific nadir. Chemotherapy agents are usually given in combinations (also called regimens or protocols). The goal of administering combination chemotherapy in cycles or specific sequences is to produce additive or synergistic therapeutic effects. Administering several medications with different mechanisms of action and different onsets of nadirs and toxicities enhances tumor cell destruction while minimizing medication resistance and overlapping toxicities.

The nurse is caring for a client with prostate cancer who is being treated with a hormone therapy. What should the nurse monitor for in order to evaluate the effect of this treatment? 1.An increase in testosterone levels 2.An increase in prostaglandin levels 3.An increase the amount of circulating androgens 4.A decline in the amount of circulating androgens

4 Rationale: Hormone therapy (androgen deprivation) is a mode of treatment for prostatic cancer. The goal is to limit the amount of circulating androgens because prostate cells depend on androgen for cellular maintenance. Deprivation of androgen often can lead to regression of disease and improvement of symptoms. The remaining options do not identify the goals of this form of treatment.

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency 1.Headache 2.Dysphagia 3.Constipation 4.Electrocardiographic changes

4 Rationale: Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave.

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? 1.At ovulation time 2.7 to 10 days after menses 3.Just before menses begins 4.At a specific day of the month and on that same day every month thereafter

4 Rationale: If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month. Options that recommend scheduling related to menses are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur.

The nurse is performing an admission assessment on a client who has a history of glaucoma and uses latanoprost eye drops. Which assessment finding would indicate a side/adverse effect of these eye drops? 1.Irregular pulse 2.Periorbital edema 3.Elevated blood pressure 4.Brown pigmentation of the iris

4 Rationale: Latanoprost is a topical medication used to lower intraocular pressure in clients with open-angle glaucoma and ocular hypertension. The most significant side/adverse effect is heightened brown pigmentation of the iris. Other side effects include blurred vision, burning, stinging, conjunctival hyperemia, and punctate keratopathy. The heightened pigmentation does not progress further once the medication is discontinued but does not regress. The other options are not noted with this medication.

The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the primary health care provider's prescriptions for the client. Which prescription should the nurse question? 1.Diazepam 2.Nicotinic acid 3.Diphenhydramine 4.Ambulation four times daily

4 Rationale: Medical interventions during the acute phase of Ménière's disease include using diazepam as prescribed to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator (nicotinic acid) also will be prescribed. The client will remain on bed rest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing.

Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the primary health care provider if which diagnosis is documented in the client's history? 1.Gout 2.Asthma 3.Myocardial infarction 4.Venous thromboembolism

4 Rationale: Megestrol acetate suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of venous thromboembolism. Options 1, 2, and 3 are not contraindications for this medication.

When teaching a client with glaucoma about the effects of a miotic medication, the nurse should tell the client that the medication will produce which effect? 1.Reshape the lens to eliminate blurred vision. 2.Dilate the pupil to reduce intraocular pressure. 3.Interrupt the drainage of aqueous humor from the eye. 4.Lower intraocular pressure and improve blood flow to the retina.

4 Rationale: Miotics are used to lower the intraocular pressure, which then increases blood flow to the retina. This in turn decreases retinal damage and loss of vision. Miotics cause a contraction or constriction of the ciliary muscle and widen the trabecular meshwork. The other options are incorrect.

Which medication, if prescribed for the client with glaucoma, should the nurse question? 1.Betaxolol 2.Pilocarpine 3.Erythromycin 4.Atropine sulfate

4 Rationale: Options 1 and 2 are miotic agents used to treat glaucoma. Option 3 is an anti-infective medication used to treat bacterial conjunctivitis. Atropine sulfate is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1.A pink-colored tympanic membrane 2.A pearly colored tympanic membrane 3.A transparent and clear tympanic membrane 4.A red, dull, thick, and immobile tympanic membrane

4 Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head

The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? 1."It's a loss of vision associated with aging." 2."A loss of balance occurs with presbycusis." 3."Presbycusis is a conductive hearing loss that occurs with aging." 4."It's a sensorineural hearing loss that occurs with the aging process."

4 Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. The statements in the remaining options are incorrect statements about this condition.

A client has been hospitalized for removal of a cervical radiation implant used to treat cancer. The implant is removed, and the nurse provides home care instructions to the client. Which statement made by the client indicates a need for further instruction? 1."Cream may be used to relieve dryness or itching." 2."Some vaginal bleeding is expected for 1 to 3 months." 3."Sexual intercourse may be resumed after 7 to 10 days." 4."Foul-smelling vaginal discharge is a sign of an infection."

4 Rationale: Some foul-smelling vaginal discharge is expected and is not a sign of an infection in this client. As well, this type of discharge will occur for some time after removal of a cervical radiation implant. All other options are accurate discharge instructions.

The nurse is caring for a client with metastatic breast cancer. The client describes a new and sudden sharp pain in the back. Based on this assessment finding, which is the prioritynursing intervention? 1.Document the findings. 2.Administer pain medication. 3.Place a heating pad on the client's back. 4.Notify the primary health care provider (PHCP).

4 Rationale: Spinal cord compression should be suspected in a client with metastatic disease, particularly with sudden onset of new back pain. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression constitutes an oncological emergency, so the PHCP should be notified. Although the nurse would document this finding, this is not the priority action. The nurse would not administer pain medication or place a heating pad on the client unless the cause of the new pain has been determined. In addition, a prescription from the PHCP is needed for the use of a heating pad.

The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if 1 of the students states that which action should be performed? 1.Perform the exam after a cold shower. 2.Expect the exam to be slightly painful. 3.Perform the self-examination every other month. 4.Roll the testicle between the thumb and forefinger.

4 Rationale: TSE is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and 20s. The examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand, and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath), when the scrotum is relaxed.

The client has undergone mastectomy. The nurse determines that the client is making the best adjustment to the loss of the breast if which behavior is observed? 1.Refusing to look at the wound 2.Reading the postoperative care booklet 3.Asking for pain medication when needed 4.Participating in the care of the surgical drain

4 Rationale: The client demonstrates the best adaptation by participating in her own care. This would include care of surgical drains that are in place for a short time after discharge. Refusing to look at the wound indicates no adaptation to the loss. Reading the postoperative care booklet is useful but is not the best of the options presented here. Asking for pain medication is an action-oriented option, but it does not relate to acceptance of the loss of the breast.

The nurse has provided instructions to a client receiving external radiation therapy. Which client statement would indicate a need for further instruction regarding self-care related to the radiation therapy? 1."I need to eat a high-protein diet." 2."I need to avoid exposure to sunlight." 3."I need to wash my skin with a mild soap and pat dry." 4."I need to apply pressure on the irritated area by wearing snug clothing to prevent bleeding."

4 Rationale: The client should avoid pressure on the irritated area and should wear loose-fitting clothing. Specific primary health care provider instructions would be necessary if an alteration in skin integrity occurred as a result of the radiation therapy. Options 1, 2, and 3 are accurate measures to implement after radiation therapy.

The home care nurse visits a client who has just returned home from the hospital after a mastectomy with a suction drain in place. Which observed client behavior requires a need for further teaching? 1.Empties the drain to prevent infection 2.Elevates the arm when lying and sitting 3.Applies lotion to the area after the incision heals 4.Performs full range-of-motion exercises to the upper arm

4 Rationale: The client should be instructed to limit upper arm range-of-motion exercises to the level of the shoulder only. Once the suction drain has been removed, the client can begin full range-of-motion exercises to the upper arm as prescribed. The client should elevate the arm while sitting down or lying, and the client will be able to apply lotion to the incision once it has healed. The drain is emptied as needed.

The nurse is providing care to a client who has undergone modified right mastectomy for the treatment of breast cancer. Which activity should the nurse incorporate into the plan of care? 1.Keep suction drains fully inflated to provide adequate suction. 2.Perform venipunctures and blood pressures on the operative side only. 3.Inform the client that drains will be removed on the second postoperative day. 4.Maintain head of the bed elevation at 30 degrees with the right arm elevated on a pillow.

4 Rationale: The client should have the head of the bed elevated at least 30 degrees with the affected arm elevated on a pillow. Keeping the affected arm elevated promotes lymphatic fluid return after removal of lymph nodes and channels. Gentle suction must be maintained on the drain bulb to prevent fluid accumulation at the operative site. With short hospital stays, drainage tubes are usually removed about 1 to 3 weeks after hospital discharge when the client returns for an office visit. All staff must avoid using the affected arm for measuring blood pressure, giving injections, or drawing blood.

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? 1.The client is asked to discriminate numbers from a chart composed of colored dots. 2.The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field. 3.The examiner and client cover their right eyes and stare at each other's left eyes, and a small object is brought into the visual field. 4.The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

4 Rationale: The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner, approximately 2 ft (60 cm) away. The eyes of the client and the examiner should be at the same level. Both the examiner and the client cover the eyes directly opposite each other and stare at each other's uncovered eye. A small object is brought from the peripheral visual field and tests the superior, temporal, inferior, and nasal field. The client states when he or she sees the object.

A client with glaucoma is given a prescription for a pilocarpine ocular system. The nurse plans to provide which instruction to the client on how to use the medication? 1.Apply ½ inch into the eye at bedtime. 2.Apply 1 drop of the solution 4 times a day. 3.Remove and replace the ocular system every 48 hours. 4.Check the eye each morning to make sure that the system is in place.

4 Rationale: The pilocarpine ocular system has a bilayered membrane surrounding a reservoir of pilocarpine solution. The tiny unit, which is placed in the conjunctival sac, slowly releases medication. The unit should be changed once a week. Because the unit may fall out during sleep, the client should check the eye each morning for its presence.

The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume? 1.Tea 2.Coffee 3.Cold-cut meats 4.Sugar-free Jell-O

4 Rationale: The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? 1.Whisper a statement while the client blocks both ears. 2.Quietly whisper a statement and test both ears at the same time. 3.Whisper a statement with the examiner's back to the client. 4.Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.

4 Rationale: To perform a voice test, the examiner stands 1 to 2 ft (30 to 60 cm) away from the client and asks the client to block 1 external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. The client is not asked to block both ears, and the examiner should face the client during the test.

The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? 1."The client's vision is normal, but the client may require reading glasses." 2."The client is legally blind, and glasses or contact lenses will not be helpful." 3."The client can read at a distance of 40 ft (12 meters) what a person with normal vision can read at 20 ft (6 meters)." 4."The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."

4 Rationale: Vision that is 20/20 is normal; that is, the client is able to read at 20 ft (6 meters) what a person with normal vision can read at 20 ft (6 meters). A client with a visual acuity of 20/40 can read at a distance of only 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters).

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? 1."You will be isolated from your newborn infant after delivery." 2."Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." 3."There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." 4."You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

4 Rationale: With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures should be obtained from potentially exposed newborn infants on the day of delivery.

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used. Select the correct sequence number for each item. 1.Asks the client to cover 1 eye 2.Examiner covers eye opposite to the eye covered by the client 3.Asks the client to report when object is first noted 4.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client 5.The examiner brings in an object gradually from periphery

4, 1, 2, 5, 3 Rationale: The confrontation test is a gross measure of peripheral vision. It compares the person's peripheral vision with the examiner's, whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, peripheral field loss is expected. The client should be referred to an eye care specialist. The procedure is conducted in the following order: stand 2 to 3 ft (60 to 90 cm) in front of the client and face him or her; client covers 1 eye on request; nurse covers the eye opposite the one covered by the client; an object is gradually brought inward from the periphery; and the client reports when the object is first noted.