med surg 2 exam 1 (test bank)
A patient is scheduled to have cataract surgery. Which structure of the patient's eye does the nurse explain will be involved in the procedure?
The lens
A patient in the plateau stage of GBS is frustrated because there has been no improvement in manifestations for 5 days. Which explanation does the nurse provide to the patient?
The manifestations can last up to 2 weeks
A patient diagnosed with Guillain-Barré syndrome (GBS) asks how the disease developed since the patient rarely has an illness. Which nursing response is the most accurate?
"It may be an autoimmune reaction to a virus."
The nurse is visiting the home of a patient who is being treated for Bell palsy. Which statement by the patient indicates that care instructions need to be reviewed by the nurse?
"Alternating heat and cold therapy is helping the swelling."
A patient with peripheral neuropathy states, "I don't know why the doctor put me on an antidepressant. I am not depressed!" Which response by the nurse is best?
"Antidepressants are sometimes used to treat nerve pain such as you are experiencing."
A patient has been on opioids for 3 months to control pain caused by injuries from a motor vehicle crash. The patient asks about the risk of withdrawal symptoms when the drugs are no longer needed. How should the nurse respond to the patient?
"As long as you taper the drug dose down slowly, you should not experience withdrawal symptoms."
The nurse is performing a pain assessment on a newly admitted patient. Which question best assesses the severity of pain?
"Can you please rate your pain on a scale of 0 to 10?"
The nurse in the emergency department is assisting with the care of a patient with a penetrating wound to the eye. The patient keeps crying out and asking that the uninjured eye be uncovered. Which answer by the nurse provides understanding?
"Covering the uninjured eye stops ocular movement in the injured one
The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement regarding symptoms indicates a correct understanding of the teaching?
"Headache and seeing halos around lights"
The nurse is collecting data from a patient in the HCP's office. Which statement by the patient indicates that the patient is likely to be having problems with some activities of daily living (ADLs)?
"I can barely lift my arms above my shoulders."
The nurse is collecting up-to-date data from a patient who was diagnosed with MS 15 years ago. The patient has a good understanding of the disease and manages to maintain a relatively high level of functioning. Which statement by the patient prompts the nurse to seek additional information?
"I love to work in my flower beds during the summer months."
The nurse places eyedrops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which patient statements indicate further instruction is needed? (Select all that apply.)
"I should exercise my patched eye four times daily." "I can watch television without moving my eye too much." "I should apply pressure to the tear duct of the eye every 5 minutes." "I should try to open my eyelid under the patch hourly while awake."
The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective?
"I will cough or sneeze with my mouth open
The nurse enters a room just as a patient's daughter pushes the button of his IV patient controlled analgesia (PCA) pump. Which response by the nurse is appropriate?
"It is dangerous for anyone but your dad to push the button. Remind him to push it himself if he needs it."
A patient who is prescribed neostigmine for newly diagnosed MG asks how the medication works. Which response does the nurse provide to the patient?
"It makes more neurotransmitters available so that your muscles can contract."
A patient with MS has been prescribed baclofen to relax muscles. Which information is included in the nurse's teaching about this drug? (Select all that apply.)
"Report any shortness of breath or other respiratory problems." "Avoid driving or operating machinery until the effects of the drug are known." "Prevent constipation by increasing fluids and fiber-rich foods; use suppositories when necessary."
The nurse is providing education for a patient being discharged with a fentanyl (Duragesic) patch. Which statements made by the patient indicate an understanding of the teaching? (Select all that apply.)
"Since I smoke, this medication may not be as effective for me." "If I am running a fever, I should avoid this medication." "I should avoid touching the medication when applying the patch."
A patient is prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson disease. Which instructions are important for the nurse to include when teaching about this medication? (Select all that apply.)
"Taking the medication with food may reduce nausea." "You may experience sudden bouts of excessive sleepiness." "Do not drive until the effects of this drug on you are fully known."
The caregiver of a patient with macular degeneration voices being increasingly frustrated because of food spills on the patient's clothing. Which explanation does the nurse give to help the caregiver understand what the patient is experiencing?
"The central vision is gone and only peripheral vision remains."
A patient has an injury resulting in a major damage to the pinna of the right ear. The patient expresses fear about hearing loss in the damaged ear. Which statement by the nurse will alleviate the patient's fear?
"The impulses for hearing come from the middle and inner ear."
A patient with chronic back pain has a new order for a fentanyl (Duragesic) patch. As the nurse applies the patch, the patient states, "I'm really glad to get that patch on. I am really hurting bad." Which response by the nurse is correct?
"The patch may take a while to work. Would you like a pain shot in the meantime?"
A mother of three young children has a 3-year history of MG and recently stopped helping in the children's classrooms because of fatigue. Which advice does the nurse give to help the patient best cope with the problem?
"Time your medication so its action peaks during the time you need the most energy."
The nurse reviews information with a patient and family members about the patient's recent diagnosis of amyotrophic lateral sclerosis (ALS). Which comment by a family member indicates a need for clarification?
"When the heart muscle is affected, death will occur shortly."
A patient is distressed to learn that a sibling is diagnosed with both neurologic and cognitive manifestations of Huntington disease. When the patient asks the nurse how to determine the incidence of the disease, which answer is most appropriate?
"You definitely need to have genetic testing for the disease."
A patient's Snellen chart findings are 20/60. Which explanation does the nurse provide to the patient regarding this finding?
"You must be at 60 feet to see what normal vision sees at 20 feet."
The nurse is planning care for a patient with a migraine headache. Which actions does the nurse include in this plan of care? (Select all that apply.)
A dark, quiet room Sumatriptan (Imitrex) rest
The nurse is caring for a group of patients. Which patient is experiencing chronic pain?
A patient who fell off a ladder 6 months ago and injured his back
The nurse is caring for a group of patients. Which patient should the nurse see first?
A patient who underwent an appendectomy 2 hours ago reporting level 8 pain on a 0-to-10 scale
The nurse is caring for a group of patients. Which patient is experiencing acute pain?
A patient with a diagnosis of pancreatitis
A patient is being admitted to a long-term care facility. Medical history includes a recent stroke with dysarthria. Which factor does the nurse consider when providing care for this patient?
A picture board will help the patient with word searching.
A patient is diagnosed with Ménière disease. Which therapeutic measures does the nurse expect the HCP to prescribe?
A salt-restricted diet and prescribed antihistamines and vasodilators
The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which equipment should the nurse expect to be used?
A tonomete
The nurse is caring for a patient who underwent an amputation of the left arm. The patient reports level 9 pain on a 0-to-10 scale. Which action should the nurse take?
Administer 4 mg of morphine intravenously as prescribed
The nurse is providing care for a patient who is experiencing difficulty eating due to a neurologic dysfunction. Which action by the nurse will be least helpful in promoting adequate nutritional intake for this patient?
Allow the patient adequate time and privacy to self-feed.
A patient comes to the emergency room exhibiting confusion and manifestations related to dementia. Records from previous visits indicate a history of drug and alcohol abuse along with frequent treatment for sexually transmitted infections (STIs). Which laboratory test does the nurse consider to be unnecessary?
Anticholinesterase testing with antibody titers
The nurse is reviewing medications prescribed for a patient experiencing pain. Which medications should the nurse realize are being used as adjuvant agents for this patient's pain? (Select all that apply.)
Anticonvulsants Benzodiazepines Tricyclic antidepressants Steroids
The nurse is assisting with care for a patient in the ICU with an extreme head injury. The HCP reports that the patient has brain herniation. Which action does the nurse expect from the HCP?
Arranging for the family to be approached about possible organ donation
A patient with a gastrostomy tube is prescribed a sustained-released opioid medication. What should the nurse do when preparing to provide this medication to the patient?
Ask the physician to prescribe the medication as an elixir for tube administration.
The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching?
Compliance with drug therapy is essential to prevent loss of vision.
The nurse is caring for a patient with an acute brain injury. Which interventions does the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.)
Avoid hip flexion. Administer stool softeners. Keep head of bed elevated 30 degrees
The nurse is collecting data from a patient with diabetes mellitus. The patient's medical history reveals multiple episodes of hyperglycemia requiring medical management. The patient tells the nurse, "I just got new glasses, but I still do not see very well." Which condition does the nurse suspect?
Background retinopathy
The nurse is reviewing orders for a patient with diabetic neuropathy. Which medication should the nurse expect to administer?
Carbamazepine (Tegretol)
A patient is brought to the emergency department after being hit by a baseball bat during a game. Which nursing intervention is immediately reported to the HCP or RN?
Changes in heart and respiratory rate, fever, and diaphoresis
The nurse is caring for a patient with metastatic cancer. The patient is receiving 4 mg of morphine intravenously every 6 hours as needed and 5 mg hydrocodone/acetaminophen (Lortab) every 6 hours orally as needed for breakthrough pain. The patient reports the medication is effective, but the medication wears off before the dose is due. The nurse notifies the health care provider. Which order should the nurse anticipate?
Changing medications to an around-the-clock schedule
The nurse is providing care for a female patient who is paralyzed from a C-4 spinal cord injury. The patient is turned and repositioned every 2 hours. Which action does the nurse take when repositioning the patient in a side-lying position?
Check that her breast is not compressed under her body
The nurse is providing care for a patient after surgery for treatment of trigeminal neuropathy. Which nursing intervention will the nurse initiate for this patient?
Check the eye on the surgery side for corneal sensation
A patient with a spinal cord injury at T3-T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.)
Check to see if the indwelling catheter is patent. Perform a rectal examination to determine if impaction is present. Monitor BP every 5 minutes.
A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests does the nurse expect to be performed prior to beginning treatment for this patient? (Select all that apply.)
Complete blood count (CBC) Rinne and Weber tests Culture of ear discharge
The nurse is preparing a patient with MG to undergo plasmapheresis. Which laboratory tests does the nurse verify and place on the medical record before the procedure?
Complete blood count, platelets, and clotting studies
During a physical examination of a patient, pupillary reflexes are checked. A light is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a light is shone into the left eye as the right eye is still observed. Which response occurs during the second step of the test?
Consensual response
While checking a patient's pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse?
Consensual response present
A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM) and atropine 0.4 mg IM. Which action does the nurse take?
Contact the physician.
The nurse is assisting in the evaluation of the effectiveness of teaching for a patient who has severe visual impairment. Which statement by the patient indicates additional teaching is needed?
Cooking is still impossible and I am just eating cold foods.
The nurse is preparing to collect data during the reassessment of a patient's neurologic status. Which equipment is unnecessary for this procedure?
Cotton ball
The nurse has reinforced teaching with a patient about diagnostic tests that evaluate eye muscle balance. Which tests identified by the patient indicate teaching has been effective? (Select all that apply.)
Cover test Corneal light reflex
The nurse is assisting with a patient who was injured in an accident and experienced head injury. The RN records the patient as exhibiting decerebrate posturing. Which condition does the nurse associate with the RN's finding?
Damage to the area of the brainstem
The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change does the nurse recognize as causing the manifestations of MS?
Demyelination and destruction of nerve fibers
The nurse is preparing to provide an opioid medication for a patient's postoperative pain. Which action should the nurse take first?
Determine the respiratory rate.
During a health history, the nurse suspects that a patient is at risk for a vision problem. Which information within the family history does the nurse use to make this decision? (Select all that apply.)
Diabetes Cataracts Blindness Glaucoma
The nurse is teaching a patient with MG how to recognize a cholinergic crisis. Which manifestations does the nurse include in this teaching? (Select all that apply.)
Diarrhea Salivation Vomiting Increased bronchial secretions
The nurse is working at a summer camp for preadolescent children. One of the children comes to the nurse rubbing an eye and stating pain from getting sand in the eye. After the child is effectively treated, which teaching is the nurse prompted to provide to all the attendees?
Do not rub your eye if it has something in it
The nurse in an HCP's office is assisting with the removal of impacted cerumen from the ear canal of an older adult patient. The patient presented with decreased hearing and a sensation of fullness. Which reason does the nurse identify as the most likely cause of the patient's condition?
Dryness of secretions from shrinking ear canal glands
A patient taking hydromorphone for cancer pain is experiencing constipation. What should the nurse teach to help this patient?
Eat a high-fiber diet and increase fluid intake
An older adult patient is hospitalized for a respiratory infection. The nurses have been placing the patient's feet into high-top tennis shoes even while in bed. Which answer does the nurse make to a family member who asks about the purpose of the shoes?
Explain that without the proper foot position, it is impossible to stand.
The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. Which actions does the nurse include in the preprocedure preparation? (Select all that apply.)
Explain to the patient that a sensation of warmth may be felt when the dye is injected. Tell the patient to report any nausea, itchiness, or difficulty breathing during the scan. Check blood urea nitrogen (BUN) and creatinine levels. Question the patient about allergies to dye, shellfish, or iodine
The nurse is preparing a review of the neurologic system as part of a community health presentation. Which structures does the nurse identify as being part of the diencephalon? (Select all that apply.)
Hypothalamus Thalamus
The nurse is caring for a patient who was in a motor vehicle accident and has multiple fractures. The patient reports level 9 pain on a 0-to-10 scale. Which route should the nurse use to administer the medication for quickest relief of pain?
IV
The nurse is collecting data from a patient with a detached retina. Which findings does the nurse expect in this patient? (Select all that apply.)
Flashing lights Loss of peripheral vision \ Loss of acuity in the affected eye
The nurse is assisting with the care of a patient after a traumatic brain injury. The patient experiences a seizure and exhibits bilateral jerking of the extremities. Which type of seizure activity does the nurse recognize?
Generalized
The nurse is providing care for a patient with a sensorineural hearing loss. Which prescribed medications does the nurse question before administering medications to this patient? (Select all that apply.)
Gentamicin Furosemide Indomethacin
The nurse suspects that a patient is experiencing increasing ICP. What observations cause the nurse to come to this conclusion? (Select all that apply.)
Headache Rising temperature Dilated pupil on affected side Decreasing level of consciousness (LOC
The nurse is assisting the RN in providing care for a patient with a potential for ICP. Which manifestation does the nurse recognize as needing to be reported to the RN?
Increased systolic blood pressure (BP)
The nurse is assisting with care of patients diagnosed with neuromuscular disorders. Which complication does the nurse recognize as a medical emergency?
Indications of the development of pneumonia
A patient presents with vertigo, tinnitus, and sensorineural hearing loss and is diagnosed with labyrinthitis. Which patient teaching does the nurse reinforce with this patient?
Instruct to not turn the head quickly
A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient's diagnosis?
Lack of involvement and lip smacking or chewing
A patient is scheduled for a thymectomy. For which peripheral nervous system disorder does the nurse plan care for this patient?
MG
The nurse is hired by a family to provide care for a family member diagnosed with stage 2 Alzheimer disease. Which action related to safety is most important for the nurse to implement?
Make sure that all doors are locked where potential risk exists
The nurse is providing care for a patient on a medical unit with a history of seizure activity. The patient exhibits the manifestations of a generalized seizure, which does not respond to prescribed treatment. Seizure activity has been continuous for over 30 minutes. Which prescription does the nurse prepare for the HCP?
Making immediate arrangements to transfer the patient to the intensive care unit (ICU)
The nurse is collecting data from a patient who is diagnosed with MG. Which data is most important for the nurse to obtain?
Monitor the patient's respiratory function and the ability to swallow effectively
The nurse is preparing a patient for neurologic testing. Which testing does the nurse expect if the patient expresses severe pain in the lower back aggravated by movement?
Myelogram
A patient receiving large doses of opioids is lethargic and difficult to arouse, with a respiratory rate of 6 per minute and constricted pupils. Which medication should the nurse anticipate being prescribed?
Naloxone (Narcan)
A patient reports that she has been having bloody stools for the past month. Which medication can the nurse expect to note on the medication history?
Naproxen (Aleve)
The nurse asks an older adult patient to count backward from 100 in increments of three; the patient counts correctly until the nurse stops the process. Which reason does the nurse identify as a likely cause of long periods of hesitation during the process?
Normal delay in problem solving
The nurse is providing care for a school-age patient at a community clinic. The patient exhibits redness and crusting exudate on the lids and corners of each eye, and reports pain and itching. A culture was taken of the exudate and antibiotic drops were prescribed. Which action does the nurse take if the eye culture returns as positive for Neisseria gonorrhoeae?
Notify the HCP and RN about a possible situation involving sexual abuse of a minor.
The nurse is collecting information about a patient's auditory system during a physical examination. Which process will the nurse perform first?
Observation
A patient with chronic pain is on a sustained-release opioid that is ordered every 12 hours. After 6 hours, the patient complains of increasing pain. Which intervention by the nurse is appropriate?
Obtain an order for an immediate-release opioid for breakthrough pain
The nurse in an HCP's office is providing assistance with a patient who has purulent drainage from the ear. Which action by the HCP does the nurse expect?
Obtaining a swab of the drainage for culture
A patient with otitis media is experiencing severe ear pain. Which nonpharmacological measures does the nurse apply to help relieve this patient's discomfort? (Select all that apply.)
Offer a massage. Apply heat to the area. Offer liquid or soft diet
The nurse is preparing to administer eye medication as prescribed by the HCP after eye surgery for cataract removal. The HCP prescribes one drop with punctal occlusion. Which action will the nurse perform when administering this medication?
Place the index finger on the corner of the eye and apply pressure against the nose bone
The nurse is assisting with the care of a patient being prepared for emergency intervention for a detached retina. If the nurse asks the patient about the ability to maintain a reclining position for 16 hours, which procedure is planned for this patient?
Pneumatic retinopexy
The nurse is working in a college infirmary when a student comes in and states, "I think I have a migraine. My head hurts, I cannot stand the light, and I feel sick to my stomach." Which additional data collected by the nurse causes concern for a different diagnosis?
Positive Brudzinski's sign
The nurse is using the FOUR tool to assess a patient's neurologic functioning. In which areas does the nurse collect data when using this tool? (Select all that apply.)
Reflexes Eye response Motor movement Breathing pattern
A patient reports to the nurse an inability to rest or sleep due to a long-term condition causing a constant urge to move the legs called restless legs syndrome (RLS). The patient expresses a need for some type of relief. Which suggestion by the nurse is most likely to help the patient?
Pramipexole or ropinrole medication therapy
The nurse is assisting with the preparation of a patient for a cochlear implant due to profound deafness. Which teaching will the nurse reinforce for this patient?
Preparation instructions for surgery
The nurse determines that a patient is experiencing common age-related changes in vision and hearing. Which findings does the nurse identify in the patient? (Select all that apply.)
Presbycusis Yellowing of the lens Distorted depth perception Decreased lacrimal secretions
The nurse is collecting information from a patient who reports difficulty seeing the print in the newspaper. The patient is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the patient is experiencing?
Presbyopia
The nurse is conducting hearing tests in a neighborhood clinic. The nurse is concerned about the number of young adult patients who exhibit signs of sensorineural hearing loss. For which reason does the nurse suspect this type of hearing loss in this population?
Prolonged exposure to loud noise
The nurse will be accompanying a patient to the radiology department for the performance of a computerized axial tomography (CAT) scan with contrast. The patient is an older adult who has pain and exhibits signs of mild agitation. Which nursing care for the patient related to the examination is inappropriate?
Provide pain medication as soon as the test is done
A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. Which intervention is appropriate for this patient?
Provide soft foods at body temperature at mealtimes
The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?
Pupils equal, round, and reactive to light and accommodation
The nurse suspects a patient is experiencing a sympathetic response. Which manifestations does the nurse expect the patient to exhibit? (Select all that apply.)
Relaxation of bladder Decrease in peristalsis Dilation of bronchioles
A patient who has just returned from abdominal surgery states, "I learned relaxation exercises, so I won't need any drugs." Which statement about relaxation therapy should the nurse use to guide care for this patient?
Relaxation therapy is an excellent adjunct treatment for pain when used with analgesics
The nurse is assisting with the care of a patient with a brain tumor who is exhibiting ICP. Which nursing intervention is specifically initiated to provide safety for this patient?
Relocate environmental objects and pad the bedside rails.
The nurse is caring for a patient who is receiving morphine via PCA. Which finding would be of most concern to the nurse?
Respirations 10 breaths/min
Prior to measuring a patient's hearing, the nurse obtains a tuning fork. Which hearing tests is the nurse preparing to conduct? (Select all that apply.)
Rinne test Weber test
The nurse is reviewing orders for a patient and notes an order for extra-strength Tylenol 2 tablets (1,000 mg) every 4 hours around the clock. What action should the nurse take?
Seek clarification from the health care provider
The nurse is preparing to assist the HCP with the incision of a carbuncle in the ear canal of a patient. Which specific manifestation does the nurse associate with the patient's diagnosis?
Several hair follicles that have formed an abscess
The nurse is providing care for a patient who was diagnosed with Parkinson disease 12 years prior. Which manifestation of the disease presents the nurse with the most likely risk for safety of this patient?
Shuffling gait
The nurse is providing care for an older adult client. The nurse notices the patient appears to be having difficulty understanding her and asks that questions and comments be repeated. If the nurse suspects presbycusis, which action does the nurse take to promote better hearing for the patient?
Speak to the patient in a lower tone of voice.
While observing the neurologist complete a neurologic examination, the nurse notes that a patient has an absent left patellar reflex. Which possible areas of dysfunction does the nurse consider? (Select all that apply.)
Spinal cord Femoral nerve Quadriceps femoris muscle
An older adult patient is experiencing the manifestation related to a neurocognitive disorder and is being transferred to a long-term care facility. Which condition will involve the nurse in reaching long-term goals related to this patient?
Suggesting the family attend a support group
A physician writes an order to give a saline injection to a patient who has been requesting frequent meperidine (Demerol) shots. Which initial response by the licensed practical nurse (LPN) is best?
Tell the physician about feeling uncomfortable administering saline if the patient thinks it is Demerol.
The nurse is collecting information about the eyes from an older adult patient. Which finding is unexpected during the examination?
The best color discrimination is between blue, green, and purple.
The nurse is providing information to a patient with migraine headaches. Which information from the patient is least likely to be useful to the HCP when prescribing treatment?
The effectiveness of resting in a dark, quiet environment
The nurse is explaining how the retina works to a patient who is experiencing visual changes. Which factor shared by the nurse is correct?
The fovea centralis is located directly behind the center of the lens and contains cones.
The nurse is monitoring a patient who is 4 years of age who fell down a flight of steps. A Babinski response was not present during the initial assessment. The RN asks the nurse to recheck for a Babinski reflex and report abnormal responses. Which response will the nurse report to the RN?
The great toe extends and the other toes fan out.
The licensed practical nurse (LPN) is assigned to assist the registered nurse (RN) in providing care for a patient admitted for an inflammatory neurologic disorder. Which reassessment finding does the LPN report immediately to the RN?
The patient attempts to get out of bed to go to work.
The nurse is providing care for a patient being treated for trigeminal neuropathy. The nurse is concerned about the patient's nutritional status because of an inability to eat without experiencing severe pain. Which patient behavior indicates the nurse's interventions are successful?
The patient can eat multiple small, soft, lukewarm meals daily
The nurse is conducting hearing acuity evaluation on a patient using the Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the documentation "AC greater than BC"?
The patient continues to hear the tuning fork for twice as long when it is lifted from the mastoid bone
The nurse is assisting with the care of a patient admitted following a fall resulting in a head injury. Which finding prompts the nurse to inform the RN that the patient is experiencing a negative change in the level of consciousness?
The patient falls asleep in the middle of a sentence.
The nurse is giving instructions to a patient who is scheduled for an electronystagmogram due to a diagnosis of vertigo and ringing in the ears. Which finding regarding the patient's medical history will cause the nurse to notify the prescribing health care provider (HCP) for cancellation of the test?
The patient has a pacemaker
A patient is brought to the health care provider's office with a headache, lethargy, nausea, vomiting, and a fever, which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information indicates a possible cause for encephalitis?
The patient has been camping within the last few weeks.
The nurse is visiting the home of a patient diagnosed with visual impairment related to macular degeneration. Which observation indicates to the nurse the patient is adjusting to the condition?
The patient is moving about in the apartment without problems.
The nurse is assisting with the care of a patient diagnosed with postpolio syndrome. The nurse asks the registered nurse (RN) to explain the source of the disease. Which answer by the RN is correct?
The patient must first have had a poliovirus infection.
A patient is diagnosed with otosclerosis and is scheduled for a stapedectomy. Which postoperative finding does the nurse report to the health care provider (HCP) or the registered nurse (RN) immediately?
The patient received an antiemetic for nausea, but vomits after the medication.
The nurse is providing care for multiple patients. Which patient does the nurse decide to report immediately to the health care provider (HCP) or the registered nurse (RN)?
The patient who begins to exhibit lack of coordination and aphasia
The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds, the patient leans to one side and exhibits a swaying motion. Which conclusion does the nurse draw from these test results?
The test is positive and indicates cerebellar dysfunction
The nurse is attending while the HCP performs an otoscopic examination of a patient's ears. The nurse is aware that the examination is performed primarily for which purpose?
To examine the eardrum
The nurse is preparing a patient with diabetes mellitus for a fluorescein angiography. For which reason does the nurse understand the performance of this test?
To find leakage or damage to the blood vessels of the retina
The nurse is caring for a patient with lung cancer who has been receiving morphine for 2 weeks and reports the medication is no longer effective. Which is the patient likely experiencing?
Tolerance
The nurse is having difficulty assessing the pain of a mentally impaired patient who has an approximate functional level of a 4-year-old child. Which method should the nurse use to determine the patient's pain level?
Use the FACES scale
The nurse is teaching a patient about nonpharmacological therapies. Which topics should the nurse include in the teaching? (Select all that apply.)
Watching television for distraction Biofeedback technique Application of heat Use of guided imagery
An adolescent patient is diagnosed by the HCP with keratitis from a herpes simplex infection of the eye. Which patient teaching does the nurse reinforce as a method for pain management?
Wearing sunglasses indoors and outdoors to decrease effects of photophobia
The nurse is conducting an initial screening to determine a patient's gross hearing acuity as part of a complete physical. Which test does the nurse include in the assessment?
Whisper voice
The National Eye Institute has performed research regarding the impact of nutrition on eye diseases. Which factor does the nurse recognize as an incorrect conclusion from this research?
With intensive glycemic control, patients with diabetes mellitus do not experience retinopathy
The nurse is collecting information from a patient in the HCP's office. The patient is exhibiting symptoms associated with Bell palsy. Which population group does the nurse recognize as being at greatest risk for the condition?
Women in the third trimester of pregnancy