Health and Illness Concept 1- EXAM 2
During a health history, a 43-yr-old teacher reports increasing difficulty reading printed materials for the past year. What change related to aging does the nurse suspect? a. Myopia b. Hyperopia c. Presbyopia d. Astigmatism
Presbyopia
which are modes of heat loss in the newborn? SATA a. radiation b. urination c. convection d. conduction e. evaporation
A,C,D,E
After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a) Initiate cooling per protocol. b) Avoid the use of sedative drugs. c) Check mental status every 15 minutes. d) Rewarm if temperature is below 91° F (32.8° C).
a) Initiate cooling per protocol.
An older man arrives in triage disoriented and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a) assess his vital signs. b) obtain a brief medical history from his wife. c) start supplemental O2 and have the provider see him. d) determine the kind of insurance he has before treating him.
a) assess his vital signs.
The school nurse is counseling an adolescent male who is returning to school after attempting suicide. He denies substance abuse and has no history of treatment for depression. He says he has no friends or family who understand him. Critical thinking encourages the nurse to consider all possibilities, including which of the following? (Select all that apply.) 1. Adolescents often explore their sexual identity and expose themselves to complications such as sexually transmitted infections (STIs) or unplanned pregnancy. 2. Peer approval and acceptance are not important in this age-group. 3. Lesbian, gay, bisexual, and transgender (LGBTQ+) youth often experience stress from identification with a sexual minority group. 4. Knowledge about normal changes associated with puberty and sexuality can decrease stress and anxiety. 5. Adolescence is a time of emotional stability and self-acceptance.
1,3,4
The nurse is providing community education about how the sexual response changes with age. Which statement made by one of the adults indicates the need for further information? 1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire." 2. "It usually takes longer for both sexes to reach an orgasm." 3. "Most of the normal changes in function are related to alteration in circulation and hormone levels." 4. "Many medications can interfere with sexual function."
1. "Health problems such as diabetes, chronic obstructive pulmonary disease, and hypertension have little effect on sexual functioning and desire."
The nurse is gathering a sexual health history on a patient being admitted to the hospital for surgery. Which question demonstrates a nonjudgmental attitude? 1. Can you tell me your sexual orientation? 2. How do you and your wife feel about intimacy? 3. Do you have sex with men, women, or both? 4. Do you have sexual intercourse at your age?
1. Can you tell me your sexual orientation?
Which patient behaviors would the nurse promote for healthy eyes (select all that apply)? a. Protective sunglasses when bicycling b. Taking part in a smoking cessation program c. Supplementing diet intake of vitamin C and beta-carotene d. Washing hands thoroughly before putting in or taking out contact lenses e. A woman avoiding pregnancy for 4 weeks after receiving MMR immunization
A,B,C,D
Which nursing diagnoses for patients with sensory perceptual variances may be included in a plan of care? (Select all that apply.) A. Impaired mobility B. Altered nutrition that is less than the body requirements C. Risk for injury D. Decreased cardiac output E. Knowledge deficit for nutrition
A,B,C
Common age-related changes in the auditory system include (select all that apply) a. drier cerumen. b. tinnitus in both ears. c. auditory nerve degeneration. d. atrophy of the tympanic membrane. e. greater ability to hear high-pitched sounds.
A,B,C,D
A college student reports eye pain after studying for finals. What assessment should the nurse make first in determining the possible cause of this eye pain? a. Do you wear contacts? b. Do you have any allergies? c. When was your last eye exam? d. Describe the changes in your vision.
a. Do you wear contacts?
the nursing instructor is talking with the junior nursing class about male reproductive issues. the instructor tells the students that the causes of erectile dysfunction include which of the following? SATA a. alcoholism b. spinal cord trauma c. tadalafil d. phosphodiesterase-5 inhibitor e. diabetes
A,B,D
Ask patients using eyedrops to treat their glaucoma about a. use of corrective lenses. b. their usual sleep pattern. c. a history of heart or lung disease. d. sensitivity to opioids or depressants.
c. a history of heart or lung disease.
which intervention would be most appropriate to include in the plan of care for a client with visual deficits? SATA a. describe the layout of the room. b. introduce yourself when entering the room. c. speak loudly when interacting with the client. d. explain the unfamiliar sounds such as alarms. e. inform the client that the call light is "over there".
A,B,D
The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that: 1. The patient cannot be sexually active since he is moving into a nursing home. 2. The patient may be requesting a private room to facilitate an intimate relationship with his partner. 3. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. 4. Older adults in nursing homes usually do not participate in sexual activity.
2. The patient may be requesting a private room to facilitate an intimate relationship with his partner.
teaching for patients with a sexually transmitted disease would include: SATA a. treatment of sexual partner is important. b. douching may help provide relief of itching. c. sexual abstinence is indicated during the communicable phase of the disease. d. condoms should be used during as well as after treatment during sexual activity.
A,C,D,E
Care of the patient experiencing an acute attack of Ménière's disease includes (select all that apply) a. giving antiemetics as needed. b. implementing fall precautions. c. keeping the room dark and quiet. d. placing the patient on NPO status. e. ambulating in the hall independently.
A,B,C
What should general teaching for patients with a sexually transmitted infection (STI) include? (Select all that apply.) A. Treatment of sexual partners. B. Douching will help to provide relief of itching. C. Importance of retesting after treatment to confirm cure. D. Cotton undergarments are preferred over synthetic materials. E. Sexual abstinence is needed during the communicable phase of a disease. F. Condoms should be used during and after treatment during sexual activity.
A,C,D,E,F
when providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? SATA a. at train stations b. cleaning their homes c. using lawnmower d. working with children e. at concerts
A,C,E
Before injecting fluorescein for angiography, it is important for the nurse to (select all that apply) a. obtain an emesis basin. b. ask if the patient is fatigued. c. administer a topical anesthetic. d. inform patient that skin may turn yellow. e. assess for allergies to iodine-based contrast media.
A,D
What should be included in the discharge teaching for the patient who had cataract surgery (select all that apply)? a. Eye discomfort is often relieved with mild analgesics. b. A decline in visual acuity is common for the first week. c. Stay on bed rest and limit activity for the first few days. d. Notify the provider if an increase in redness or drainage occurs. e. Following activity restrictions is essential to reduce intraocular pressure.
A,D,E
the nurse is providing discharge instructions to a client with glaucoma. which activities does the nurse instruct the client to avoid. SATA a. bending over to tie shoes. b. sitting with legs elevated. c. sleeping on more than two pillows. d. blowing the nose frequently. e. lifting objects weighing more than 10lbs.
A,D,E
A patient with hypothermia is brought to the emergency department. What treatment should the nurse anticipate? A. Core rewarming with warm fluids B. Gastric tube feedings to increase fluids C. Frequent oral temperature assessment D. Ambulation to increase metabolism
A. Core rewarming with warm fluids
The nurse is teaching a family about sensory alterations. The nurse needs to provide additional teaching if a family member makes which statement? A. "My cousin has autism, and I am going to hug him more so he understands how much I care." B. "If I stop smoking, I might enjoy eating more!" C. "I am going to wear earplugs when I mow the lawn." D. "So grandpa's stroke is why he thinks his left arm and leg aren't there any more."
A. My cousin has autism, and I am going to hug him more so he understands how much I care.
The nurse is admitting a patient to the emergency room on a cold winter night. Which assessment finding would cause the nurse to suspect hypothermia? A. Slow capillary refill B. Red, sweaty skin C. Rapid pulse rate D. Increased respirations
A. Slow capillary refill
Although sexual activity is considered a normative process, some individuals place themselves at increased risk for negative consequences related to this process. Which nonsexual behavior is likely to increase risk-taking activities? A. Using alcohol, marijuana, or illicit substances B. Having multiple sexual partners C. Having gay, lesbian, or bisexual partners D. Refraining from safe-sex practices such as condom use
A. Using alcohol, marijuana, or illicit substances
The most important intervention for the patient with epidemic keratoconjunctivitis is a. cleansing the affected area with baby shampoo. b. monitoring spread of infection to the opposing eye. c. regular instillation of artificial tears to the affected eye. d. teaching the patient and caregivers good hygiene techniques.
d. teaching the patient and caregivers good hygiene techniques.
A man with a primary infection of genital herpes was prescribed acyclovir (Zovirax) orally for 10 days. The patient returns to the clinic for a follow-up visit. Which finding indicates that treatment is effective? Negative bacterial culture Absence of genital lesions Reduction of genital warts No drainage from chancre sore
Absence of genital lesions
When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? Swimmer's ear Acute otitis media Impacted cerumen Chronic otitis media
Acute otitis media
Which event discovered during pregnancy would alert the nurse that a cesarean section delivery is indicated? A.Contact with a person with syphilis 2 weeks ago B. Treatment for gonococcal pharyngitis before conception C. Treatment for C. trachomatis at her 20th week of gestation D. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery
D. Active herpes simplex virus type 2 vesicles on her cervix at the time of delivery
A young male patient is seeking treatment for recurrence of genital tingling, burning, and itching. The nurse will expect a prescription for which class of medications? Antivirals Antibiotics Vaccination Contraceptives
Antivirals
After an acoustic neuroma is removed from a patient, the nurse teaches the patient about tumor recurrence. What should the nurse instruct the patient to monitor? (Select all that apply.) a. Lack of coordination b. Episodes of dizziness c. Worsening of hearing d. Inability to close the eye e. Clear drainage from the nose
B,C,D
a 55 year old male presents to the health care clinic with reports of decreased hearing over the past year. which subjective data in the clients review of systems. should the nurse recognize as risk factors for hearing loss? SATA a. use of antihypertensive medication. b. chronic ear infections as a child. c. history of measles at 3 years of age. d. wax blocking the ear canal. e. drinks six cups of coffee daily.
B,C,D
Teach the patient who is newly fitted with bilateral hearing aids to (select all that apply) a. replace the batteries monthly. b. clean the ear molds weekly or as needed. c. clean ears with cotton-tipped applicators daily. d. disconnect or remove the batteries when not in use. e. initially restrict usage to quiet listening in the home.
B,D,E
The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a) Continuously monitor heart rhythm. b) Give acetaminophen (Tylenol) 650 mg. c) Assess neurologic status every 2 hours. d) Place cooling blankets above and below patient. e) Attach rectal temperature probe to cooling blanket control panel.
B,D,E
Which strategies would best aid the nurse communicate with a patient who has a hearing loss (select all that apply)? a. Overenunciate speech. b. Speak normally and slowly. c. Exaggerate facial expressions. d. Raise the voice to a higher pitch. e. Write out names or difficult words.
B,E
The patient is being treated for a recurrent episode of Chlamydia. What should the nurse include in patient teaching? A. If you are treated, your sexual partner will not need to be treated. B. Abstain from sexual intercourse for 7 days after finishing the treatment. C. You will probably get gonorrhea if you have another recurrence of Chlamydia. D. Because you have been treated before, you do not need to take all the medication this time.
B. Abstain from sexual intercourse for 7 days after finishing the treatment.
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. Which action by the nurse caring for the child requires the nurse manager to intervene? A. Obtains electronic equipment for monitoring the vital signs B. Adjusts the bed to the Trendelenburg position C. Secures a pump to administer the ordered intravenous fluids D. Places a hypothermia blanket at the bedside
B. Adjusts the bed to the Trendelenburg position
What clinical indicator will the nurse likely identify when assessing a patient with pyrexia? A. Elevated blood pressure B. Increased pulse rate C. Precordial pain D. Dyspnea
B. Increased pulse rate
In a patient with vertigo, the parts of the ear most likely involved are the (select all that apply) a. cochlea. b. ossicles. c. vestibule. d. semicircular canals. e. tympanic membrane.
C,D
In working with teenagers, what should the nurse include when teaching about prevention of STIs? A. Spermicidal jellies reduce the risk of getting STIs. B. Douches for women and cleaning the penis will prevent STIs. C. Abstinence and then latex barriers, such as condoms, are the best prevention. D. Getting an STI is embarrassing so you will want to use preventive measures.
C. Abstinence and then latex barriers, such as condoms, are the best prevention.
Which is the priority nursing invention for a patient with hyperthermia? A. Initiating seizure precautions B. Limiting oral intake C. Removing excess clothing D. Providing a blanket
C. Removing excess clothing
A 24-yr-old patient is at the clinic with symptoms of purulent vaginal discharge, dysuria, and dyspareunia. She is sexually active and has multiple partners. What should the term-110nurse explain as the rationale for Chlamydia screening? A. Chlamydia is frequently comorbid with HIV. B. Untreated chlamydia infections can lead to sepsis. C. Untreated chlamydia infections may cause infertility. D. Chlamydia infections are treatable only in the early stages.
C. Untreated chlamydia infections may cause infertility.
A patient comes to the clinic after being informed by a sexual partner of possible recent exposure to syphilis. The nurse will examine the patient for what characteristic finding of syphilis in the primary clinical stage? Chancre Alopecia Condylomata lata Regional adenopathy
Chancre
The nurse obtains a history from a 34-year-old man diagnosed with chlamydia. Which patient statement indicates additional teaching is required? A. "This infection can be cured by taking antibiotics." B. "It is important to use condoms for all sexual activity." C. "I will avoid sexual contact for 1 week after taking the antibiotics." D. "My sexual partner does not have symptoms and will not need treatment."
D. "My sexual partner does not have symptoms and will not need treatment."
The patient has a history of cardiovascular disease and has developed erectile dysfunction. He is frustrated because he is taking nitrates and cannot take erectogenic medications. What should the nurse do first? A. Give the patient choices for penile implant surgery. B. Recommend counseling for the patient and his partner. C. Obtain a thorough sexual, health, and psychosocial history. D. Assess levels of testosterone, prolactin, luteinizing hormone, and thyroid hormones.
D. Assess levels of testosterone, prolactin, luteinizing hormone, and thyroid hormones.
A 15-year-old female patient has come to the office for her annual physical and first pelvic examination. In this situation, which nursing action is most important? Ensure the patient that all information will be kept confidential. Screen for possible abuse. Excuse the parent. Encourage the patient to ask questions about sexuality.
Excuse the parent.
An unresponsive 79-yr-old patient is admitted to the emergency department during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to: a) apply wet sheets and a fan to the patient. b) provide O2 at 2 L/min with a nasal cannula. c) start lactated Ringer's solution at 1000 mL/hr. d) give acetaminophen (Tylenol) rectal suppository.
a) apply wet sheets and a fan to the patient.
In order to fully understand the concept of sexuality, it is necessary to become familiar with the terms used when discussing this topic. Which term best describes how one views oneself as masculine or feminine? Sexual behavior Sexual identity Gender identity Sexual orientation
Gender identity
A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? Hearing loss Exophthalmos Conjunctivitis Recurrent fever
Hearing loss
Otoscopic examination of the patient's left ear indicates the presence of an exostosis. What does the nurse teach the patient about regarding the growth? Surgery Electrocochleography Monitoring of the growth Irrigation of the ear canal
Monitoring of the growth
The nurse administers a Gardasil vaccine to an 18-yr-old female patient. After the injection, which patient instruction is priority? Avoid sexual activity for 24 to 48 hours. Remain lying down for at least 15 minutes. Return to the clinic in 6 months for a second dose. Use two methods of birth control to avoid pregnancy.
Remain lying down for at least 15 minutes.
A homeless person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestation would the nurse expect? A. Rapid respirations B. Increased anxiety C. Erythema D. Stupor
Stupor
When examining the patient's ear with an otoscope, the nurse observes discharge in the canal and the patient reports pain with the examination. What should the nurse next assess the patient for? Sebaceous cyst Swimmer's ear Metabolic disorder Serous otitis media
Swimmer's ear
A patient with septic shock is receiving multiple medications. The nurse assesses which intravenous (IV) medication is the most likely to cause a hearing loss? Aspirin Dopamine Ampicillin Vancomycin
Vancomycin
A triage nurse in the emergency department assesses a patient who reports 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to: a) assess the patient's current vital signs. b) give acetaminophen (Tylenol) per agency protocol. c) ask the patient to provide a clean-catch urine for urinalysis. d) tell the patient that it will be 1 to 2 hours before seeing a health care provider.
a) assess the patient's current vital signs.
The nurse teaches a patient prescribed dipivefrin eyedrops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? a. "The eyedrops could cause a fast heart rate and high blood pressure." b. "I will need to take the eyedrops twice a day for at least 2 to 3 months." c. "I may have eye discomfort and redness from the use of these eyedrops." d. "I will apply gentle pressure on the inside corner of my eye after each eyedrop."
a. "The eyedrops could cause a fast heart rate and high blood pressure."
Which intervention would be part of the plan of care for a patient who has new vision loss? a. Allow the patient to express feelings of grief and anger. b. Have the UAP perform all self-care activities for the patient. c. Address any family present first when discussing care concerns. d. Speak loudly and clearly, addressing the patient with each contact.
a. Allow the patient to express feelings of grief and anger.
The patient reports a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? a. Amsler grid test b. B-scan ultrasonography c. Fluorescein angiography d. Intraocular pressure testing with Tono-Pen
a. Amsler grid test
The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? a. Discard all opened or used lens care products. b. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. c. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. d. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.
a. Discard all opened or used lens care products.
A patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? a. Eat a light meal before the procedure. b. Avoid carbonated beverages before the procedure. c. Take nothing by mouth for 3 hours before the procedure. d. No special dietary restrictions are needed until after the procedure.
a. Eat a light meal before the procedure.
The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? a. Hypertension and diabetes b. Hypothyroidism and polycythemia c. Atrial fibrillation and atherosclerosis d. Vascular dementia and chronic fatigue
a. Hypertension and diabetes
An older adult patient states they do not seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? a. Look for cerumen in the ear. b. Assess for increased hair growth in the ear. c. Tell the patient it is probably related to aging. d. Ask the patient if he has fallen because of dizziness.
a. Look for cerumen in the ear.
a student nurse is doing clinical hours at an OB/GYN clinic. the student is helping to develop a plan of care for a patient with gonorrhea has presented at the clinic. the student knows that the care plan for this patient should be to include what in the treatment of gonorrhea? a. concurrent treatment for chlamydia b. a avoidance of the use of tampons c. vaginal smears every 6 months d. radiation therapy to destroy cancerous cells.
a. concurrent treatment for chlamydia.
the nurse is providing immediate postoperative care for a 3 month old who has a cataract removed. which intervention would be the priority? a. ensuring the protective eye patch is securely in place. b. teaching the family how to use antibiotic eye drops. c. explaining to the parents about patching the eye as therapy. d. instructing parents about using protective sunglasses.
a. ensuring the protective eye patch is securely in place.
The patient who has a conductive hearing loss a. hears better in a noisy environment. b. hears sound but does not understand speech. c. often speaks loudly because his or her own voice seems low. d. has clearer sound with a hearing aid if the loss is less than 30 dB.
a. hears better in a noisy environment.
the nurse has notes that the physician has a diagnosis of prebycusis on the clients chart. the nurse plans care knowing the conditions is: a. sensorineural hearing loss that occurs with aging. b. conductive hearing loss that occurs with again. c. tinnitus that occurs with aging. d. nystagmus that occurs with again.
a. sensorineural hearing loss that occurs with aging.
which of the following statements best describes the relationship between biologic sex and gender identity? a. sex is chromosomally determined, while gender is a psychosocial construct. b. biologic sex and gender identity are both modifiable by surgery and medical interventions. c. biologic sex and gender identity are considered synonyms in nursing practice. d. biologic sex is genetically determined but gender identity is chosen during adolescence.
a. sex is chromosomally determined, while gender is a psychosocial construct.
which describes perception? a. the ability to interpret impulses transmitted from the receptors that give meaning to the stimuli. b. the process of receiving stimuli in the nerve ending. c. a response to stimuli that declines over time. d. anything that stimulates a nerve receptor.
a. the ability to interpret impulses transmitted from the receptors that give meaning to the stimuli.
Always assess the patient with an eye problem for a. visual acuity. b. pupillary reactions. c. intraocular pressure. d. confrontation visual fields.
a. visual acuity.
A patient has a core temperature of 90°F (32.2°C). The most appropriate rewarming technique would be a) passive rewarming with warm blankets. b) active internal rewarming using warmed IV fluids. c) passive rewarming using air-filled warming blankets. d) active external rewarming by submersing in a warm bath.
b) active internal rewarming using warmed IV fluids.
The triage nurse at an ambulatory clinic receives a call from a person with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this potential eye injury? a. "Remove any visible metal fragments." b. "Apply a loose dressing over your eyes." c. "Rinse your eyes immediately with water." d. "Keep your eyes open to allow tears to form."
b. "Apply a loose dressing over your eyes."
While summarizing teaching about genital herpes, which patient statement indicates a need for further instruction? a. "No cure is available for my genital herpes." b. "I will utilize my medication when I begin to have symptoms." c. "Genital herpes may be caused by herpes simplex virus type 1 or 2" d. "I am not able to infect a sexual partner unless I have active lesions."
b. "I will utilize my medication when I begin to have symptoms."
The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? a. "This is often due to an infection that will resolve on its own." b. "Many people experience an age-related decline in their hearing." c. "This is likely an effect of your medications. Try stopping them for a few days." d. "You can accommodate for your hearing loss with a few small changes in your routine."
b. "Many people experience an age-related decline in their hearing."
When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? a. "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." c. "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." d. "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."
b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve."
A patient reports intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? a. "Do you use ginkgo to treat asthma symptoms?" b. "What do you take if you have allergy symptoms?" c. "Are you taking propranolol for anxiety disorder?" d. "Are you currently taking prednisone (Deltasone)?"
b. "What do you take if you have allergy symptoms?"
A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks. What should the nurse include in the discharge teaching for this patient? a. Airplane travel will be more comfortable now. b. Avoid sudden head movements or position changes. c. Cough or blow the nose to keep the Eustachian tubes clear. d. Take antihistamines, antiemetics, and sedatives for recovery.
b. Avoid sudden head movements or position changes.
Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? a. Absence of pain or pressure b. Blurred vision in the morning c. Seeing colored halos around lights d. Eye pain accompanied with nausea and vomiting
b. Blurred vision in the morning
A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect? a. Redness and swelling of the conjunctiva b. Drooping of the upper lid margin in one or both eyes c. Redness, swelling, and crusting along the eyelid margins d. Small, superficial white nodules along the eyelid margin
b. Drooping of the upper lid margin in one or both eyes
When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? a. Giving anticipatory guidance about the loss of central vision that will occur b. Encouraging compliance with drug therapy for the glaucoma to prevent vision loss c. Recognizing that eye damage caused by glaucoma can be reversed in the early stages d. Managing the pain patients with glaucoma have that persists until the optic nerve atrophies
b. Encouraging compliance with drug therapy for the glaucoma to prevent vision loss
A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? a. Photorefractive keratectomy (PRK) b. Phakic intraocular lenses (phakic IOLs) c. Refractive intraocular lens (refractive IOL) d. Laser-assisted in situ keratomileusis (LASIK)
b. Phakic intraocular lenses (phakic IOLs)
What assessment technique should the nurse use to assess an adult patient's tympanic membrane? a. Have the patient tilt the head toward the nurse. b. Stabilize the otoscope with your fingers on the patient's cheek. c. Pull the auricle down and back to straighten the auditory canal. d. Use a speculum slightly larger than the size of the patient's ear canal.
b. Stabilize the otoscope with your fingers on the patient's cheek.
The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates improvement of the middle ear infection? a. Fenestrations are visible in the tympanic membrane. b. Tympanic membrane is gray, shiny, and translucent. c. Cone of light is not visible on the tympanic membrane. d. Tympanic membrane is blue and bulging with no landmarks.
b. Tympanic membrane is gray, shiny, and translucent.
the nurse is caring for a 6 year old child with sensorineural hearing loss. which would the nurse be least likely to identify as the cause of the child's hearing loss? a. ototoxic medication use b. acute otitis media c. intrauterine exposure to rubella d. excess noise exposure
b. acute otitis media
In a patient who has a hemorrhage in the posterior cavity of the eye, the nurse knows that blood is accumulating a. in the aqueous humor. b. between the lens and retina. c. between the cornea and lens. d. in the space between the iris and lens.
b. between the lens and retina.
the nurse is caring for a child after surgical removal of a brain tumor. the nurse should assess the child for which sign that would sign that would indicate that brainstem involvement occurred during the surgical procedure? a. inability to swallow b. elevated temperature c. altered hearing ability d. orthostatic hypotension.
b. elevated temperature
A man 50 years of age has a long history of diabetes, which is poorly controlled. what does diabetes greatly increase the mans risk of experiencing. a. STI b. erectie dysfunction c. retarded ejaculation d. premature ejaculation
b. erectie dysfunction
The nurse is surveying the assisted living facility regarding safety features for patients with sensory deficits. Which are the most appropriate accommodations? A. Steps painted with dark colors B. Fire and smoke alarms with sound and flashing lights C. Colorful throw rugs to designate the purpose of various rooms D. Alarms on all exit doors
b. fire and smoke alarms with sound and flashing lights.
a male patient comes to the clinic and is diagnosed with gonorrhea. which symptoms most likely prompted him to seek medical attention? a. painful red papule on the shaft of the penis. b. foul-smelling discharge from the penis. c. rated on the palms of the hands and soles of the feet. d. cauliflower-like warts on the penis.
b. foul-smelling discharge from the penis.
the nurse is obtaining the history from the parents of an infant who is suspected of having infantile glaucoma. which statement by the parents would help to confirm this suspicion? a. our child's eye looks about the same size as the other eye. b. it seems like bright lights really bother our child. c. our child opens the eyes quite frequently when awake. d. our child's eye doesn't seem to tear much.
b. it seems like bright lights really bother our child.
The nurse teaches a patient scheduled for an electronystagmography that the test involves a. measuring ear drum movement in response to pressure. b. recording eye movements associated with ear irrigation. c. placing an electrode on the eardrum and assessing for dizziness. d. wearing headphones and determining which sounds can be heard.
b. recording eye movements associated with ear irrigation.
a client treated for an episode of hyperthermia is being discharged to home. the nurse determines hat the client needs clarification of discharge instructions if the client states a need to perform which action? a. increase fluid intake b. resume full activity level. c. stay in a cool environment when possible. d. monitor voiding for adequacy of urine output.
b. resume full activity level.
the nurse has applied a hypothermia blankets to a client with a fever. a priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? a. frostbite b. skin breakdown c. venous insufficiency d. arterial insufficiency
b. skin breakdown
Presbyopia occurs in older people because a. the eyeball elongates. b. the lens becomes inflexible. c. the corneal curvature becomes irregular. d. light rays are focusing in front of the retina.
b. the lens becomes inflexible.
the nurse is educating the parents of a 7 year old child who has hearing loss due to otitis media with effusion. which statement by the parents indicates that further education is needed? a. we need to make sure we are speaking clearly. b. we need to raise the volume of our voices significantly so our child can hear us. c. we need to face our child when we are speaking. d. using hand gestures as visual cues should help our child understand a little better.
b. we need to raise the volume of our voices significantly so our child can hear us.
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department. The nurse determines that discharge teaching has been effective when the patient makes which statement? a) "I'll take salt tablets when I work outdoors in the summer." b) "I should take two acetaminophens if I start to feel too warm." c) "I need to drink extra fluids when working outside in hot weather." d) "I'll move to a cool environment if I notice that I'm feeling confused."
c) "I need to drink extra fluids when working outside in hot weather."
A patient comes to the outpatient clinic for treatment of uncomplicated gonorrhea. Which patient statement requires immediate clarification by the nurse? a. "I should avoid alcohol use for at least 2 weeks." b. "I will have my sexual partner come in for treatment." c. "After I start the antibiotic, it is safe to have sex again." d. "After treatment, I do not need to return to the clinic for retesting."
c. "After I start the antibiotic, it is safe to have sex again."
The nurse is preparing to administer timolol eyedrops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? a. "I have sinusitis." b. "I have migraine headaches a lot." c. "I have chronic obstructive pulmonary disease." d. "I have a history of chronic urinary tract infections."
c. "I have chronic obstructive pulmonary disease."
The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? a. "I doubt my other eye will ever be affected." b. "I can expect severe pain after this procedure." c. "I should avoid lifting heavy objects and straining." d. "The procedure will correct my vision immediately."
c. "I should avoid lifting heavy objects and straining."
A patient says she was diagnosed with astigmatism. When she asks what that is, what is the best explanation the nurse can give to the patient? a. "It happens because the lens of the eye is absent." b. "People with astigmatism have abnormally long eyeballs." c. "The cornea of the eye is uneven or irregular with astigmatism." d. "Astigmatism occurs because the eye muscles weaken with age."
c. "The cornea of the eye is uneven or irregular with astigmatism."
When assessing an adult patient's external ear canal and tympanum, what assessment techniques should the nurse use? a. Ask the patient to tip their head toward the nurse. b. Note a pearly gray tympanic membrane as a sign of infection. c. Gently pull the auricle up and backward to straighten the canal. d. Identify a normal light reflex by the appearance of irregular edges.
c. Gently pull the auricle up and backward to straighten the canal.
When administering eyedrops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? a. Apply pressure to each eyeball for a few seconds after administration. b. Have the patient close the eyes and move them back and forth several times. c. Have the patient put pressure on the inner canthus of the eye after administration. d. Have the patient try to blink out excess medication immediately after administration.
c. Have the patient put pressure on the inner canthus of the eye after administration.
A patient newly diagnosed with glaucoma asks the nurse what has made the pressure in the eyes so high. Which is the nurse's most accurate response? a. Back pressure from cardiac congestion causes corneal edema. b. Cerebral venous dilation prevents normal interstitial fluid resorption. c. Increased production of aqueous humor or blocked drainage increases pressure. d. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.
c. Increased production of aqueous humor or blocked drainage increases pressure.
A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? a. Initiate coping strategies to reduce stress. b. Identify patient's strengths and support system. c. Verbalize feelings related to visual impairment. d. Transition successfully to the sudden vision loss.
c. Verbalize feelings related to visual impairment.
during patient teaching regarding self-administration of ophthalmic drops, which statement by the nurse is correct? a. hold the eyedrops over the cornea, and squeeze out the drop. b. apply pressure to the lacrimal duct area of 5 minutes after administration. c. be sure to place the drop in the conjunctival sac of the lower lid. d. squeeze you eyelid closed tightly after placing the drop into your eye.
c. be sure to place the drop in the conjunctival sac of the lower lid.
the nurse is teaching a community health class of women and explains that a sexually transmitted infections is associated with an increased risk of infertility in women. which of the following STIs would the nurse identify? a. herpes simplex b. syphilis c. chlamydia d. gonorrhea
c. chlamydia
the nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections is? a. spermicides b. a cervical cap c. condoms d. a diaphragm
c. condoms
What is associated with the resolution phase of the male sexual response cycle? a. intense physical pleasure b. the ability to begin the excitement phase again. c. feelings of relaxation and fulfillment d. increased blood flow to the penis
c. feelings of relaxation and fulfillment.
A patient reports tinnitus and balance problems. The medication that may be responsible is a. digoxin. b. warfarin. c. furosemide. d. acetaminophen.
c. furosemide
a client with a neurological problem is experiencing hyperthermia. which measure would be least appropriate for the nurse to use in trying to lower the client's body temperature? a. giving tepid sponge baths b. applying a hypothermia blanket c. placing ice packs in the axilla and groin areas. d. administering acetaminophen (Tylenol) per protocol.
c. placing ice packs in the axilla and groin areas.
a female client informs the nurse that her husband is concerned about her sexual response. the client reports that during stimulation her husband has noticed her clitoris disappears, and he wonders if she is enjoying the experience despite her positive responses to his stimulation. the nurse explains that building excitement and the reaction of the clitoris are normal characteristics of which stage of the sexual response cycle? a. resolutions phase b. orgasm c. excitement phase d. plateau phase
d. plateau phase
a client who is receiving therapy with a hypothermia blanket starts to shiver. the nurse raises the blanket temperature and monitors the client. after 15 mins the clients temperature has not increased and the client is still shivering. what should the nurse do next? a. apply a smaller heating pad to the clients axillae and neck areas. b. wait 10 more minutes and then check the clients temperature again. c. remove the hypothermia blanket and notify the clients health care provider. d. increase the blankets temperature again and recheck the clients temperature in 15 minutes.
c. remove the hypothermia blanket and notify the clients health care provider.
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming? a) The patient begins to shiver. b) The BP decreases to 86/42 mm Hg. c) The patient develops atrial fibrillation. d) The core temperature is 94° F (34.4° C).
d) The core temperature is 94° F (34.4° C).
The nurse is assessing an older adult patient who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess for the presence of presbycusis? a. "Do you ever experience any ringing in your ears?" b. "Have you ever fallen down because you became dizzy?" c. "Do you ever have pain in your ears when you're chewing or swallowing?" d. "Have you noticed any change in your hearing in recent months and years?"
d. "Have you noticed any change in your hearing in recent months and years?"
The nurse is teaching a patient about timolol eyedrops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? a. "I may feel some palpitations after instilling these eyedrops." b. "I should withhold this medication if my blood pressure becomes elevated." c. "I should keep my eyes closed for 15 minutes after instilling these eyedrops." d. "I may have some temporary blurring of vision after instilling these eyedrops."
d. "I may have some temporary blurring of vision after instilling these eyedrops."
The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? a. "Prolonged eye irritation is an expected adverse effect of this medication." b. "This medication will help to raise intraocular pressure to a near normal level." c. "This medication needs to be continued for at least 5 years after your initial diagnosis." d. "It is important not to do activities requiring visual acuity immediately after administration."
d. "It is important not to do activities requiring visual acuity immediately after administration."
A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? a. Teach about visual enhancement techniques. b. Assess coping strategies and support systems. c. Teach nutritional strategies to improve vision. d. Assess impact of vision on normal functioning.
d. Assess impact of vision on normal functioning.
During the course of a health history to assess vision, a patient reports dry eyes. What should the nurse assess next? a. Assess for contact lenses. b. Suggest saline eyedrops. c. Ask about eyeglass usage. d. Check the medication list.
d. Check the medication list.
When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? a. Inner canthus b. Outer canthus c. Center of the eyeball d. Lower conjunctival sac
d. Lower conjunctival sac
When examining the patient's eyes, which finding would be of most concern to the nurse? a. Intraocular pressure of 16 mm/Hg b. Slightly yellowish cast of the sclera c. Outward turning of the lower lid margin d. Small, white nodule on the upper lid margin
d. Small, white nodule on the upper lid margin
A patient voices an understanding of instructions about furosemide (Lasix) when he makes which statement? A. "I know that I need to monitor my feet for possible skin changes." B. "I expect that this will cause me to have increased sensitivity to saltiness." C. "I will report any blurred vision." D. "If I notice ringing in my ears, I will call the doctor."
d. if I notice ringing in my ears, I will call the doctor.
Increased intraocular pressure may occur because of a. edema of the corneal stroma. b. dilation of the retinal arterioles. c. blockage of the lacrimal canals and ducts. d. increased aqueous humor production by the ciliary process.
d. increased aqueous humor production by the ciliary process.
a 16 year old patient comes to the free clinic and is diagnosed with primary syphilis. the patient states that she contracted this disease by holding hands with someone who has syphilis. what is the most appropriate nursing diagnosis for this patient? a. alteration in comfort related to impaired skin integrity. b. fear related to complications. c. noncompliance with treatment regimen related to age. d. knowledge deficit related to modes of transmission.
d. knowledge deficit related to modes of transmission.
A normal finding the nurse would expect when assessing hearing would be a. absent cone of light. b. bluish purple tympanic membrane. c. fluid level at hairline in the tympanum. d. midline tone heard equally in both ears.
d. midline tone heard equally in both ears.
the ability to receive and interpret stimuli is a priority for what human need? a. mobility b. socialization c. nutrition d. safety
d. safety
the nurse is developing a plan of care for a client with new hearing aids. which long-term goal is most appropriate for the client? a. the client will wear the hearing aids 90% of the time. b. the client will demonstrate successful insertion of the hearing aids. c. the client will verbalize an understanding of the need for hearing aids. d. the client will demonstrate how to properly care for the hearing aids within 2 weeks.
d. the client will demonstrate how to properly care for the hearing aids within 2 weeks.
a nurse is teaching a client with genital herpes. educations for this client should include an explanation of: a. why the disease is transmittable only when visible lesions are present. b. the need for the use of petroleum products. c. the option of disregarding safer-sex practices now that he's already infected. d. the importance of informing his partners of the disease.
d. the importance of informing his partners of the disease.
A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? Vertigo Syncope Dizziness Nystagmus
dizziness
