NUR 243- exam 3 study set

A nurse is administering brimonidine eye drops to a client who has glaucoma. Which of the following ocular effects should the nurse expect? A. Decreased intraocular pressure B. Blocked growth of new blood vessels C. Paralysis of accommodation D. Mydriasis

A. Decreased intraocular pressure Rationale: Brimonidine is an alpha-2 adrenergic agonist used for the long-term treatment of open-angle glaucoma. It decreases intraocular pressure by reducing aqueous humor production.

A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? (Select all that apply.) A. Obtain the client's PT and IN measurements B. Administer lactulose 30 mL PO 4 times daily C. Obtain daily weight and abdominal girth measurements D. Administer a daily multivitamin E. Place the client on a low-protein diet

A. Obtain the client's PT and IN measurements B. Administer lactulose 30 mL PO 4 times daily C. Obtain daily weight and abdominal girth measurements D. Administer a daily multivitamin Rationale: Cirrhosis interferes with the liver's ability to produce clotting factors, which places the client at risk of hemorrhage. The PT and INR are usually prolonged due to decreased synthesis of prothrombin. A client who has cirrhosis is unable to eliminate ammonia from the body once protein is broken down. Therefore, lactulose should be administered to increase the client's production of stool, which will help eliminate ammonia from the client's body. Additionally, the nurse should anticipate a prescription to assess the client's weight daily to assess the client's fluid status. An increase of 1 kg (2.2 (b) in the client's weight indicates 1 L of fluid retention. The nurse should also expect to measure the client's abdominal girth daily to determine if ascites is increasing or decreasing. Cirrhosis also leads to deficiencies in many daily vitamins; therefore, the nurse should anticipate a prescription to administer a daily multivitamin to the client.

A nurse in a provider's office is assessing a client who has GERD. The nurse should expect the client to report which of the following manifestations? (Select all that apply.) A. Regurgitation B. Nausea C. Belching D. Heartburn E. Weight loss

A. Regurgitation B. Nausea C. Belching D. Heartburn Rationale: Regurgitation and heartburn are primary manifestations of GED. Nausea and belching are also common manifestations.

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? A. Suction equipment B. Clean gloves C. Blankets D. Oxygen

A. Suction equipment Rationale: The greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis; therefore, the nurse must have suction equipment available for clearing the mouth of secretions or emesis to reduce this risk.

A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? A. "You need to conserve energy at this time." B. "Lying quietly in bed helps slow down the activity in your intestines." C. "Staying in bed promotes the rest and comfort you need." D. "Staying in bed will help prevent injury and minimize your fall risk."

B. "Lying quietly in bed helps slow down the activity in your intestines." Rationale: The greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and gastrointestinal bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea.

A nurse in a provider's office is assessing a client who has GERD. When documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? A. Stair-climbing B. Bending over C. Sitting D. Walking

B. Bending over Rationale: Gastroesophageal reflux symptoms are most evident with activities that increase intraabdominal pressure (e.g. bending over, straining, lifting, and lying down).

A nurse is teaching a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? A. Maternal-fetal B. Fecal-oral contamination C. Genital sexual contact D. Blood to blood

B. Fecal-oral contamination Rationale: Hepatitis A is most commonly transmitted by the fecal-oral route, usually through ingesting food or liquid that has been infected with the virus. Outbreaks from contaminated food are usually due to poor hygiene practices by food handlers or shellfish sourced from contaminated water.

A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A. "I am unable to donate blood." B. "I will need to get a booster shot of immune serum globulin every year." C. "I should stop eating raw clams." D. "I can develop this disease by getting a tattoo."

C. "I should stop eating raw clams." Rationale: Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at an increased risk of acquiring hepatitis A.

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the puncta after instilling the medication D. Place each drop of the medication directly onto the client's cornea

C. Apply pressure to the puncta after instilling the medication Rationale: The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication.

A nurse is providing teaching to the parent of a toddler who has bacterial conjunctivitis. Which of the following instructions should the nurse include? C A. Clean secretions from the infected eye by wiping from the outer canthus toward the inner canthus and upward B. Keep the infected eye covered with warm compresses for the first 24 to 48 hr C. Notify the provider immediately if the sclera becomes inflamed D. Apply pressure to the outer canthus of the eye for 1 min after administering the eye drops

C. Notify the provider immediately if the sclera becomes inflamed Rationale: Although the conjunctiva becomes inflamed during this infection, the sclera should remain clear and white. If the sclera becomes inflamed, it can indicate the presence of a serious conjunctival infection, and the child should be assessed immediately by an ophthalmologist.

A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? A. Increasing the workload of the liver by releasing stored glycogen B. Causing ulceration of liver tissue that can lead to bleeding C. Dilating veins in the portal circulation D. Destroying liver cells that are later replaced with scar tissue

D. Destroying liver cells that are later replaced with scar tissue Rationale: The development of cirrhosis in a client who consumes alcohol is related to liver inflammation and cell destruction. Over time, nonfunctional scar tissue and fibrosis replace the necrotic liver cells.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Lost vision can improve with eye drops. B. Administer eye drops as needed for vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor. Rationale: Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm.

A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects? A. Increases blood pressure B. Prevents esophageal bleeding C. Decreases heart rate D. Reduces ammonia levels

D. Reduces ammonia levels Rationale: Lactulose is a laxative that promotes the excretion of ammonia in a client who has hepatic encephalopathy from cirrhosis of the liver.

A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? A. "An aura is a sensory warning that a seizure is imminent." B. "An aura is a continuous seizure in which seizures occur in rapid succession." C. "An aura is a period of sleepiness following the seizure." D. "An aura is a brief loss of consciousness accompanied by staring."

A. "An aura is a sensory warning that a seizure is imminent." Rationale: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.

A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss

A. Aspiration Rationale: Aspiration is a common complication of GED, which results when the esophageal sphincter malfunctions and allows gastric acid and undigested food to back up into the esophagus. This places the client at risk of aspiration. GERD causes effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which are an indication of aspiration.

A nurse is caring for a client who has an acute exacerbation of Cron's disease. Which of the following actions should the nurse take? A. Ensure bowel rest B. Offer sparkling water frequently C. Administer a stool softener D. Offer plain warm tea frequently

A. Ensure bowel rest Rationale: Clients who have an exacerbation of Cohn's disease usually require NP status to ensure bowel rest and promote healing and recovery.

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT)

A. Gamma-glutamyl transferase (GGT) Rationale: The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? A. Grilled chicken B. Potato soup C. Fish sticks D. Baked ham

A. Grilled chicken Rationale: The nurse should identify that a client who has cirrhosis requires protein to compensate for disease-related weight loss. Increasing protein intake from animal or plant sources will also provide the client with more energy.

A nurse at an ophthalmology clinic is assessing a client referred by the provider for a potential cataract. Which of the following client reports is consistent with cataracts? A. Halos when looking at lights B. Loss of peripheral vision C. Bright flashes of light and floaters D. Eyestrain and headaches with close work

A. Halos when looking at lights Rationale: A cataract is a cloudy or opaque area in the lens of the client's eye. Cataracts in adults usually develop with advancing age and can be hereditary. Cataracts develop slowly and painlessly with a gradual onset of difficulty with vision. Visual problems include difficulty seeing at night, halos around lights or glare sensitivity, and decreased visual acuity even in daylight. Cataracts are accelerated by environmental factors such as cigarette smoke or other toxic substances or in response to metabolic diseases such as diabetes mellitus.

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

B. Anorexia Rationale: Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

B. Glaucoma Rationale: The nurse should identify that an obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye.

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure

B. Opacity visible behind the pupil Rationale: With a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when the nurse shines a light on the area.

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts

B. Retinal detachment Rationale: A flash of light and a sudden loss of vision are manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement

C. Liver transplant Rationale: Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision

C. Severe eye pain Rationale: Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting.