ADH Exam 2

what is metacognition?

the examination of ones own reasoning or thought processes, to help refine thinking skills

In your role as a community health nurse, you are focusing your current health promotion efforts on diseases that are disproportionately represented among ethnic and racial minorities. Which of the following diseases would you likely address? Select all that apply. A) Human immunodeficiency virus (HIV) B) Cancer C) Heart disease D) Chronic obstructive pulmonary disease (COPD) E) Alzheimers disease

A, B, C Feedback: Ethnic and racial minorities are disproportionately burdened with cancer, heart disease, diabetes, human immunodeficiency virus (HIV), infection/acquired immunodeficiency syndrome (AIDS), and other conditions. COPD and Alzheimers disease are incorrect because health care disparities have not been noted with these two diseases.

normal finding of rinne test

AC>BC

A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Decreased blood pressure D) Sudden agitation

C Feedback: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? A) Exostoses B) Otalgia C) Sensorineural hearing loss D) Presbycusis

C Feedback: Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing or cranial nerve VIII. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Presbycusis is the term used to refer to the progressive hearing loss associated with aging. Both middle and inner ear age-related changes result in hearing loss.

CVID

Common variable immunodeficiency

A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18%

D Feedback: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is Malnutrition Neutropenia Hypocalcemia Chronic diarrhea

Malnutrition Explanation: The most prevalent cause of immunodeficiency worldwide is severe malnutrition.

what med is used in open-angle glaucoma?

Pilocarpine

A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection? Trimethoprim-sulfamethoxazole Nystatin Amphotericin B Fluconazole

Trimethoprim-sulfamethoxazole Explanation: To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.

Minears disease

Vertigo (dizziness) tinnitus (ringing in ears)

discharge teaching after mastoid surgery should include what?

avoid heavy lifting, straining, exertion, nose blowing for 2-3 weeks after srugery to prevent dislodging the tympanic membrane graft or ossicular prosthesis

what is the normal intraocular pressure?

between 10-21 mmHg

otosclerosis

hardening of the bony tissue of the middle ear

myringotomy

incision into the tympanic membrane

what is acculturation

process by which members of a cultural group adapt to or learn how to take on the behaviors of another group

are sharp shooting pains following tympanoplasty and mastoidecomy common?

yes

does glaucoma require lifelong pharmacologic treatment?

yes

There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency. "Your diagnosis was inherited." "Your condition will predispose you to frequent and recurring infections." "Your immune system was most likely affected by an underlying disease process." "You will now be more likely to develop cancer in the future."

"Your immune system was most likely affected by an underlying disease process." Explanation: A secondary immunodeficiency is the result of an underlying disease process or the treatment of a disorder. It is not genetically inherited. Some examples of a secondary immunodeficiency are chronic stress and diabetes mellitus.

what are the 3 major paradigms used to explain the causes of disease and illness?

-biomedical or scientific view -naturalistic or holistic perspective -magico-religious view

what is a stapedectomy

-very successful time-tested procedure, resulting in the restoration of conductive hearing loss. lengthy rehab is not normally required -removal of the stapes of the middle ear and insertion of a graft and prosthesis -performed to restore hearing with otosclerosis -done under local anesthesia with microscope; the graft is from body tissue

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of: 5 to 10 mm Hg. 10 to 20 mm Hg. 20 to 30 mm Hg. over 30 mm Hg.

10 to 20 mm Hg. Explanation: Normally, pressure in the anterior chamber of the eye remains relatively constant at 10 to 20 mm Hg.

When a nurse infuses gamma globulin intravenously, the rate should not exceed 1.5 mL/min 3 mL/min 6 mL/min 10 mL/min

3 mL/min Explanation: The intravenous infusion should be administered at a slow rate, not to exceed 3 mL/min.

The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male patient. How many grams will the nurse administer? 15 g 30 g 60 g 90 g

30 g Explanation: The optimal dose is determined by the patient's response. In most instances, an IV dose of 200-800 mg/kg of body weight is administered every 3-4 weeks to ensure adequate serum levels of immunoglobulin G (IgG).

A patient is on highly active antiretroviral therapy (HAART) for the treatment of HIV. What does the nurse know would be an adequate CD4 count to determine the effectiveness of treatment for a patient per year? 1 mm3 to 10 mm3 10 mm3 to 20 mm3 20 mm3 to 45 mm3 50 mm3 to 150 mm3

50 mm3 to 150 mm3

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time? 6 weeks 12 weeks 18 weeks 24 weeks

6 weeks Explanation: Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.

what decible level can lead to hearding loss?

80 to 90 dB

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit B) Decreased prothrombin time (PT) C) Potassium deficit D) Decreased hematocrit

A Feedback: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, base-bicarbonate deficit, and elevated hematocrit. PT does not typically decrease.

Family members are caring for a patient with HIV in the patients home. What should the nurse encourage family members to do to reduce the risk of infection transmission? A) Use caution when shaving the patient. B) Use separate dishes for the patient and family members. C) Use separate bed linens for the patient. D) Disinfect the patients bedclothes regularly.

A Feedback: When caring for a patient with HIV at home, family members should use caution when providing care that may expose them to the patients blood, such as shaving. Dishes, bed linens, and bedclothes, unless contaminated with blood, only require the usual cleaning.

Meniere's disease

Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).

Which of the following classification of medications is the most common cause of ototoxicity? Aminoglycosides Cephalosporins Sulfonamides

Aminoglycosides Explanation: IV medications, especially the aminoglycosides, are the most common cause of ototoxicity, and they destroy the hair cells in the organ of Corti. Cephalosporins, sulfonamides, and penicillins are not among the most common causes of ototoxicity.

Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing? School nurse Hearing aide salesperson Audiologist Nursing assistant

Audiologist Explanation: Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely. Options A, B, and D can screen hearing but they cannot do audiometric testing.

Which of the following tests determines initiation of antiretroviral treatment? CD4/CD8 ratio Enzyme immunoassay (EIA) Western blot Viral load

CD4/CD8 ratio Explanation: The CD4/CD8 ratio determines initiation of antiretroviral treatment and use of prophylactic medications. EIA is an enzyme immunoassay that detects HIV antibodies. The Western blot test detects antibodies to HIV and is used to confirm EIA. Viral load quantifies HIV RNA in the plasma. It monitors efficacy of antiretroviral treatment through virological suppression.

Which of the following brain structures is responsible for equilibrium? Cerebellum Brainstem Thalamus Hypothalamus

Cerebellum Explanation: Body balance is maintained by the cooperation of the muscles and joints of the body (proprioceptive system), the eyes (visual system), and the labyrinth (vestibular system). These areas send information about equilibrium, or balance, to the brain (cerebellar system) for coordination and perception in the cerebral cortex. The brainstem, thalamus, and hypothalamus do not function in equilibrium.

Which medication classification increases aqueous fluid outflow in the client with glaucoma? Beta-blockers Alpha-adrenergic agonists Carbonic anhydrase inhibitors Cholinergics

Cholinergics Explanation: Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis, and opening the trabecular meshwork. Beta-blockers decrease aqueous humor production. Alpha-adrenergic agonists decrease aqueous humor production. Carbonic anhydrase inhibitors decrease aqueous humor production.

A client who has been fitted with a hearing aid comes for a follow-up evaluation. During the visit, the client states, "I've noticed that I still don't seem to hear well enough. The hearing aid doesn't seem to make the sounds louder." Which of the following might the nurse determine as the possible cause? Ear mold is loose. Client has cerumen in the ear. The mold is not properly fitted. The client has an ear infection.

Client has cerumen in the ear. Explanation: The client reports that the hearing aid is not helping, such that the sounds are not loud enough. This statement is consistent with inadequate amplification. Cerumen in the ears is a possible cause. A loose ear mold would cause a whistling noise. An improperly fitted mold or middle ear infection would lead to pain from the mold.

The two underlying goals of transcultural nursing are to provide which of the following? Choose the two that apply. Culture-specific care Culture-universal care Culture-diverse care Culture-ethnic care

Culture-specific care Culture-universal care Explanation: The underlying focus of transcultural nursing is to provide culture-specific and culture-universal care that promotes the well-being or health of individuals, families, groups, communities, and institutions.

The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes

D Feedback: A 5-minute interval between successive eye drop administrations allows for adequate drug retention and absorption. Any time frame less than 5 minutes will not allow adequate absorption.

The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching? A) Try to induce a sneeze every 4 hours to equalize pressure. B) Be sure to exercise to reduce fatigue. C) Avoid sleeping in a side-lying position. D) Dont blow your nose for 2 to 3 weeks.

D Feedback: The patient is instructed to avoid heavy lifting, straining, exertion, and nose blowing for 2 to 3 weeks after surgery to prevent dislodging the tympanic membrane graft or ossicular prosthesis. Side-lying is not contraindicated; sneezing could cause trauma.

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? Delirium Pain Anxiety Fever

Delirium Explanation: Delirium is a confused state that has a sudden onset and can last hours to days or weeks; it is characterized by hyperactivity and has the potential to be reversible. The client who quickly becomes confused and agitated while attempting to pull out IV lines and get out of bed is experiencing delirium. The nurse caring for this client should anticipate the need to provide close monitoring to prevent injury. Although clients can experience a high level of stress with both pain and anxiety, which often accompany one another, these problems do not cause confusion and disorientation. Nursing interventions would be aimed at reducing pain and anxiety with the use of medications and other non-pharmacological interventions that enhance client comfort. Although fever can accompany delirium, it does not produce confusion and disorientation on its own. Reference:

Which of the following is the first barrier method that can be controlled by the woman? Female condom IUD Diaphragm Birth control pills

Female condom Explanation: The female condom has the distinction of being the first barrier method that can be controlled by the woman. The IUD may increase the risk for HIV transmission through an inflammatory foreign body response. The female condom is as effective in preventing pregnancy as other barrier methods, such as the diaphragm and the male condom. Birth control pills are not a barrier method.

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply. Flank pain Shaking chills Tightness in the chest Hunger Fatigue

Flank pain Shaking chills Tightness in the chest Explanation: Adverse reactions can include reports of flank and back pain, shaking chills, dyspnea, and tightness in the chest, as well as headache, fever, and local reaction at the infusion site.

what are the cultural phenomena of Giger and Davidhizer's assessment model in guiding nurses in exploring cultural phenomena that might affect nursing care?

Giger and Davidhizar identified communication, space, time orientation, social organization, environmental control, and biologic variations as relevant phenomena

The upper eyelid normally covers the uppermost portion of the iris and is innervated by which cranial nerve? III I IV II

III Explanation: The upper lid is innervated by the oculomotor nerve (CN III). Cranial nerve I is the olfactory nerve, cranial nerve II is the optic nerve, and cranial nerve IV is the trochlear nerve.

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started? Antibiotic therapy Immunosuppressive agents Chest physiotherapy Anticoagulation

Immunosuppressive agents Explanation: For a client undergoing a hematopoietic stem cell transplant, immunosuppression is started to ensure engraftment of depleted bone marrow. Antibiotic therapy may or may not be indicated. Chest physiotherapy would be appropriate for clients with ataxia-telangiectasis who have chronic lung disase. Anticoagulation would not be used.

Which of the following site is the source of most microbes leading to bacterial infection? Intestinal tract Respiratory tract Skin Mucous membranes

Intestinal tract Explanation: When the wound is healing, it must be protected from infection. A primary source of bacterial infection is the patient's intestinal tract, the source of most microbes. The respiratory tract, skin, and mucous membranes are not the source of most microbes.

nystagmus

Involuntary rapid eye movements

Which substance may be used to lubricate a condom? Skin lotion Baby oil K-Y jelly Petroleum jelly

K-Y jelly Explanation: K-Y jelly is water-based and will provide lubrication while not damaging the condom.The oils in skin lotion and petroleum jelly, and baby oil, will cause a latex condom to break.

Which action should the nurse recommend to a client with blepharitis? Soak the area in warm water Incision and drainage Keep lid margins clean Sleep with the face parallel to the floor

Keep lid margins clean Explanation: Instructions on lid hygiene (to keep the lid margins clean and free of exudates) are given to the client. Treatment of a stye includes warm soaks of the area and incision and drainage. The client is not required to sleep with the face parallel to the floor.

what is the opioid antagonist?

Naloxone (Narcan)

A client is suspected to have an immunodeficiency disorder. The health care provider orders a nitroblue tetrazolium reductase (NTR) test to diagnose this client. What does the nurse suspect that this disorder is related to? Complement B lymphocytes T lymphocytes Phagocytic cells

Phagocytic cells Explanation: Diagnosis of phagocytic cell disorders is based on the history, signs, and symptoms, and laboratory analysis by the nitroblue tetrazolium reductase test, which indicates the cytocidal (causing death of cells) activity of the phagocytic cells.

Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as containing the genetic viral material? Deoxyribonucleic acid (DNA) Ribonucleic acid (RNA) Viral core Glycoprotein envelope

Ribonucleic acid (RNA) Explanation: HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding

Epley maneuver

Series of head movements to relieve symptoms of benign positional vertigo place the patient in a sitting position, turning the head to a 45 degree angle on the AFFECTED side, and then quickly moving the patient to the supine position. don't put saline in to the ears

A client has received the results of a HIV antibody test, which is positive. What is the best explanation for the nurse to give to the client? The client has been infected and has produced antibodies. The client cannot transmit the virus to others. The HIV infection confirms the presence of AIDS. The antibodies indicate immunity.

The client has been infected and has produced antibodies. Explanation: A positive test result indicates HIV infection, but it does not mean that the client has AIDS. The client is not immune to HIV and can transmit the virus to others.

The nurse is assessing the auricles of a patient. When the left auricle is manipulated, the patient complains of pain. What does this finding indicate? The patient may have seborrheic dermatitis. The patient may have an inner ear infection. The patient may have acute external otitis. The patient may have acute otitis media.

The patient may have acute external otitis. Explanation: Manipulation of the auricle does not normally elicit pain. If this maneuver is painful, acute external otitis is suspected (Weber & Kelley, 2010).

A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately? Mouth sores Sneezing Constipation Tickle in the throat

Tickle in the throat Explanation: Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction.

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment? To hasten formation of scar tissue To prevent vision loss To eliminate the need for medical care To serve as a stopgap measure until help arrives

To prevent vision loss Explanation: Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.

When discussing diseases of the middle ear, the nursing instructor distinguishes the different types of otitis media. What generally causes purulent otitis media? Irritation associated with respiratory allergies and enlarged adenoids Bronchial tree Outer ear Upper respiratory infections

Upper respiratory infections Explanation: Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections. It is not caused from the bronchial tree, the outer ear or irritation associated with respiratory allergies, and enlarged adenoids.

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what? Peripheral edema Uncoordinated muscle movement Vascular lesions caused by dilated blood vessels A condition marked by development of urticaria

Vascular lesions caused by dilated blood vessels Explanation: Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia refers to uncoordinated muscle movement and is a clinical manifestation of combined B-cell and T-cell deficiencies. Telangiectasia is not peripheral edema, vascular lesions, or urticaria.

contractures

a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.

what is pilocarpine?

a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. blurred vision lasting 1-2 hrs after instilling the eye drops is an expected adverse effect. the patient may also note difficulty adapting to the dark. because blurred vision is an expected adverse effect, the drug does not need to be withheld, nor does the physician need to be notified. likewise, the patient does not need to be treated for an allergic reaction. wearing glasses will not alter this temporary adverse effect.

what are some signs of peritoneal irritation?

abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, rebound tenderness, changes in bowel sounds

what are cultural taboos

activities or behaviors that are avoided, forbidden, or prohibited by a particular cultural group

what kind of virus causes conjunctivitis?

adenovirus

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client. allograft xenograft autograft slit graft

allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

what would be performed as a last resort for a pt who cannot breathe on their own?

cricothyroidotomy

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: provide instructions on eye patching. assess the client's visual acuity. demonstrate eyedrop instillation. teach about intraocular lens cleaning.

demonstrate eyedrop instillation. Explanation: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.

A patient visited a health clinic with a complaint that her hearing aid was making a whistling noise. The nurse is aware that this hearing aid problem occurs frequently when the: batteries die. wires became disconnected. ear mold loosens or wears out. excess cerumen in the ear causes an obstruction.

ear mold loosens or wears out. Explanation: Refer to Box 50-3 in the text.

what is an ESI

emergency severity index

what is a common symptom of retinal detachment?

flashing lights in the visual field, they may also report spots or floaters or sensation of a curtain being pulled across the eye retinal detachment is not associated with eye pain, loss of color vision, or colored halos around lights

do pt have hyper or hypokalemia from a burn?

hyperkalemia

what health condition could be a major cuase of vision loss?

hypertension

iridotomy

incision of the iris

labrynthitis

inflammation of the inner ear characterized by sudden onset of incapacitatin vertigo, nausea, vomiting, hearing loss, possibly tinnitis

what is a cochlear implant for?

it's an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who don't benefit from conventional hearing aids.

The nurse is explaining metastatic rhabdomyosarcoma to a group of parents with children diagnosed with the disease. The most common site of metastasis in clients diagnosed with rhabdomyosarcoma is the brain. lung. bone. lymph nodes.

lung. Explanation: The most common site of metastasis in clients diagnosed with rhabdomyosarcoma is the lungs. The brain, bone, and lymph nodes are not common sites of the metastasis in this type of tumor.

what should a patient with cataract extraction with intraocular lens implant report?

new floaters, flashing lights, decrease in vision, pain, increase in redness

An older adult client reports pain in the ears and an unusual sense of fullness. The client also indicates not hearing as well as in the past. On inspection, the nurse notes that there is an accumulation of earwax in the client's ears. The client is suffering from: otalgia. otitis externa. otosclerosis. tinnitus.

otalgia. Explanation: Otalgia is ear pain or an earache. Otalgia has several causes, one of which is accumulated earwax

A majority of clients with CVID develop which type of anemia? Hemolytic Pernicious Macrocytic Sickle cell

pernicious

A client has noticed needing to hold printed material at arms length to make the print readable. What is the term used to describe this visual condition? presbyopia myopia hyperopia emmetropia

presbyopia Explanation: Presbyopia is associated with aging and results in difficulty with near vision. People with presbyopia hold reading material or handwork at a distance to see it more clearly.

why is it hyperkalemia after burn?

results from massive cell destruction

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. semen urine breast milk blood vaginal secretions

semen breast milk blood vaginal secretions Explanation: There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.

what structure of the ear is involved with otosclerosis

stapes

The lower the client's viral load, the shorter the time to AIDS diagnosis. the longer the survival time. the shorter the survival time. the longer the time immunity.

the longer the survival time. Explanation: The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretrovial therapy is to achieve and maintain durable viral suppression.

aspirin can cause what in terms of hearing?

tinnitus and hearing loss signs of ototoxicity

what nerves are at risk with a mastoidectomy?

facial nerve

what should the tympanic membrane look like?

pearly, grey and translucent

tinnitus

ringing in the ears (internal origin)

natural dbridement

sponatneous separations of dead tissue from vible tissue

In which religious group is pork the only meat prohibited? Seventh-Day Adventists Catholics Hindus Mormons

7th day adventists In Hinduism, all meat is prohibited. In Seventh-Day Adventism, Judaism, and Islam, pork is prohibited.

Which of the following occurs when there is deviation from perfect ocular alignment? Strabismus Ptosis Chemosis Nystagmus

Strabismus Explanation: Strabismus is a condition in which there is deviation from perfect ocular alignment. Ptosis is a drooping eyelids. Chemosis is edema of the conjunctiva. Nystagmus is an involuntary oscillation of the eyeball.

What is the model that describes the process of thinking like a nurse?

The clinical judgement model

what is a subgroup?

division of a group that is in some way distinguished from the larger group

what health condition is a risk for glaucoma?

diabetes

is recurrent serous otitis media an age-related change?

no--can indicate a nasopharyngeal cancer

what does minority mean?

refers to a group of people whose physical and cultural characteristics differ from the majority of people in a society

rinne test

useful for distinguishing between conductive and sensorineural hearing loss. hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer? "This test measures visual acuity." "This test measures how well your eyes move." "This test is to see how well your eyes are aging." "This test measures peripheral vision and detects gaps in the visual field."

"This test measures peripheral vision and detects gaps in the visual field." Explanation: A visual field examination or perimetry test measures peripheral vision and detects gaps in the visual field.

A client diagnosed with a cataract comes into the clinic. What assessments should the nurse observe in this client? A burning sensation and the sensation of an object in the eye Blurred or cloudy visual image Inability to produce sufficient tears A swollen lacrimal caruncle

Blurred or cloudy visual image Explanation: When a cataract forms, the light is blocked from reaching the macula and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle.

The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should understand that this patients health history likely includes which of the following? Select all that apply. A) The patient was diagnosed with sensorineural hearing loss. B) The patients hearing did not improve appreciably with the use of hearing aids. C) The patient has deficits in peripheral nervous function. D) The patients hearing deficit is likely accompanied by a cognitive deficit. E) The patient is unable to lip-read.

A, B Feedback: A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. The need for a cochlear implant is not associated with deficits in peripheral nervous function, cognitive deficits, or an inability to lip-read.

After working with a patient who has human immunodeficiency (HIV) for several weeks, the nurse has become more aware of the role of health disparities. Which of the following variables are known to underlie health disparities? Select all that apply. A) Poverty B) Isolated geographic location C) Overdependence on publicly funded facilities D) Male gender E) Allergy status

A, B, C Feedback: Many reasons are cited for these disparities, including low socioeconomic status, health behaviors, limited access to health care because of poverty or disability, environmental factors, and direct and indirect manifestations of discrimination. Other causes include lack of health insurance; overdependence on publicly funded facilities; and barriers to health care, such as insufficient transportation, geographic location (not enough providers in an area), cost of services, and the low numbers of minority health care providers. Male gender and a patients allergy status are not identified as contributors to health disparities.

A hospitals written policies and procedures are being reviewed as part of an accreditation process. Which of the following policies are congruent with the principles of culturally competent nursing care? Mark all that apply. A) A policy that outlines the appropriate use of translation services B) A policy guiding staff in the care of patients with different values C) A policy that requires staff from different cultures on each unit D) A policy that establishes flexible regulations pertaining to visitors E) A policy that gives priority to patients born outside the United States

A, B, D Feedback: Policies that promote culturally competent care establish flexible regulations pertaining to visitors (number, frequency, and length of visits), provide translation services for nonEnglish-speaking patients, and train staff to provide care for patients with different cultural values. Cultural competence does not depend on culturally diverse staff on every unit and it does not necessarily prioritize the interests of individuals born outside the country.

Which of the following implanted hearing devices transmits sound through the skull to the inner ear? Bone conduction devices Cochlear implant Conventional hearing aid Semi-implantable hearing device

Bone conduction devices Explanation: Bone conduction devices, which transmit sound through the skull to the inner ear, are used in patients with a conductive hearing loss if a hearing aid is contraindicated. A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. A conventional hearing aid is external only.

The results of a patients most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following potential causes? Select all that apply. A) Hepatitis B) Acute renal failure C) HIV D) Malignant melanoma E) Cholecystitis

A, C Feedback: Viral illnesses have the potential to cause ITP. Renal failure, malignancies, and gall bladder inflammation are not typical causes of ITP.

Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply. A) Enhancing the nurses clinical decision making B) Identifying the patients individual preferences C) Planning the best nursing actions to assist the patient D) Increasing the accuracy of the nurses judgments E) Helping identify the patients priority needs

A, C, D, E Feedback: Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires; these would be identified by asking the patient.

A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. A) Dysrhythmias B) Hypothermia C) Hypotension D) Hyperglycemia E) Delirium

A, C, E Feedback: The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.

The nurse is providing care to a client who implements some of the principles and practices of Complementary and Integrative Health. What should the nurse include when planning this client's care? Select all that apply. Accommodating special dietary considerations Facilitating visits to the facility by a shaman Scheduling times for the client to receive reflexology treatments Providing a safe and quiet place for performing yoga Teaching staff about the risks and benefits of acupuncture

Accommodating special dietary considerations Providing a safe and quiet place for performing yoga Explanation: The practitioner prescribes modalities such as yoga, herbal medicine, fasting and eating cleansing foods, meditation, and massage. Acupuncture and reflexology are treatment modalities that are not components of Complementary and Integrative Health. The shaman plays a central role in Native-American medicine.

The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately? Chalazion Acute angle-closure glaucoma Hordeolum Blepharitis

Acute angle-closure glaucoma Explanation: Acute angle-closure glaucoma is an emergency where the nurse should refer the client for medical treatment immediately because vision may be permanently lost in 1 to 2 days. Treatment of a chalazion is not necessary if the cyst is small and does not interfere with vision. Occurrence of a hordeolum or blepharitis is not an emergency and may be treated with warm soaks or frequent washing of the eye.

Which type of glaucoma presents an ocular emergency? Acute angle-closure glaucoma Normal tension glaucoma Ocular hypertension Chronic open-angle glaucoma

Acute angle-closure glaucoma Explanation: Acute angle-closure glaucoma results in rapid progressive visual impairment. Normal tension glaucoma is treated with topical medication. Ocular hypertension is treated with topical medication. Chronic open-angle glaucoma is treated initially with topical medications, with oral medications added at a later time.

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as: Chronic open-angle. Normal tension. Acute angle-closure. Chronic angle-closure.

Acute angle-closure. Explanation: Acute angle-closure glaucoma is characterized by the symptoms listed, as well as by being rapidly progressive and accompanied by pain.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? Administer analgesic medications as ordered. Keep the hand in the circulating bath for 1 hour. Rupture any hemorrhagic blebs that are noted. Have the client complete active range-of-motion exercises.

Administer analgesic medications as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and unruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures.

When administering a patients eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A) Ensure that the patient is well hydrated at all times. B) Encourage self-administration of eye drops. C) Occlude the puncta after applying the medication. D) Position the patient supine before administering eye drops.

C Absorption of eye drops by the nasolacrimal duct is undesirable because of the potential systemic side effects of ocular medications. To diminish systemic absorption and minimize the side effects, it is important to occlude the puncta. Self-administration, supine positioning, and adequate hydration do not prevent this adverse effect.

The nurse is conducting a community education class on cultural diversity. The nurse explains that cultural sensitivity includes which of the following? Knowledge of cultural preferences Individualized care for patients Evaluating cultural knowledge deficits Detecting cultural competence barriers

Knowledge of cultural preferences Explanation: Cultural sensitivity is being alert to and having knowledge of cultural preferences. Evaluation of cultural knowledge deficits and the detection of cultural competence barriers are components of cultural humility. Provision of individualized care for clients is a part of culturally competent nursing care.

Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella? Photorefractive keratectomy (PRK) Laser-assisted in situ keratomileusis (LASIK) Keratoconus Keratoplasty

Laser-assisted in situ keratomileusis (LASIK) Explanation: LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is a cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue.

A physician is assessing a client's ear and notes excess bone formation around the oval window. Which additional assessment finding should the nurse anticipate? Sclerosed tympanic membrane Equal bone and air conduction Low-frequency hearing loss Chronic ear infections

Low-frequency hearing loss Explanation: Excess bone formation around the oval window indicates otosclerosis, which is characterized by low-frequency hearing loss. The tympanic membrane is normal, not sclerosed, with this disorder, and bone conduction usually occurs longer than air conduction. Chronic ear infections aren't a characteristic of otosclerosis.

Which of the following are common sites of visceral involvement of Kaposi's sarcoma? Select all that apply. Lymph nodes Gastrointestinal tract Lungs Brain Heart

Lymph nodes Gastrointestinal tract Lungs Explanation: The most common sites of visceral involvement are the lymph nodes, the gastrointestinal tract, and the lungs. Involvement of internal organs may eventually lead to organ failure, hemorrhage, infection, and death. The brain and the heart are not common sites.

HIV is harbored within which type of cell? Lymphocyte Platelet Erythrocyte Nerve

Lymphocyte Explanation: Because HIV is harbored within lymphocytes, a type of white blood cell, any exposure to infected blood results in significant risk of infection. HIV infection is not harbored in platelets, erythrocytes, or nerve cells.

Which part of the retina is responsible for central vision? Macula Optic disk Sclera Fundus

Macula Explanation: The macula is the area of the retina responsible for central vision. The optic disk is the point of entrance of the optic nerve into the retina. The sclera helps maintain the shape of the eyeball and protects the intraocular contents from trauma. The fundus is the largest chamber of the eye and contains the vitreous humor.

Which is the most common cause of visual loss in people older than 60 years of age? Glaucoma Macular degeneration Cataracts Retinal detachment

Macular degeneration Explanation: Macular degeneration is the most common cause of visual loss in people older than 60 years of age.

The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find? Clear cornea Constricted pupil Marked blurring of vision Watery ocular discharge

Marked blurring of vision Explanation: Glaucoma is often called the "silent thief of sight" because most patients are unaware that they have the disease until they have experienced visual changes and vision loss. The patient may not seek health care until he or she experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.

The two types of inherited B-cell deficiencies result from lack of differentiation of B cells. These types result from which two of the following deficiencies? Choose the two that apply. Mature B-cells Plasma cells Combined B- and T-cells Complement production

Mature B-cells Plasma cells Explanation: Two types of inherited B-cell deficiencies exist. The first type results from lack of differentiation of B-cell precursors into mature B cells. As a result, plasma cells are absent, and the germinal centers from all lymphatic tissues disappear, leading to a complete absence of antibody production against invading bacteria, viruses, and other pathogens.

The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack? Meclizine (Antivert) Furosemide (Lasix) Cortisporin otic solution Gentamicin (Garamycin) intravenously

Meclizine (Antivert) Explanation: Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack (NIDCD, 2010).

Which group of medications causes pupillary constriction? Mydriatics Miotics Beta-blockers Adrenergic agonists

Miotics Explanation: Miotics cause pupillary constriction. Mydriatics cause pupillary dilation. Beta-blockers decrease aqueous humor production. Adrenergic agonists increase aqueous outflow but primarily decrease aqueous production with an action similar to that of beta-blockers and carbonic anhydrase inhibitors.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? Moisten with sterile water only. Moisten with saline. Use topical antimicrobials with Acticoat burn dressing. Keep Acticoat saturated.

Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for? Astigmatism Anisometropia Myopia Presbyopia

Myopia Explanation: Some people have deeper eyeballs, in which case the distant visual image focuses in front of, or short of, the retina; those with myopia Impaired Vision are said to be nearsighted and have blurred distance vision.

The nurse cares for a client in the burn unit. What is an early sign of sepsis in the client with burn injury? Hyperthermia Decreased pulse rate Clammy skin Narrowing pulse pressure

Narrowing pulse pressure Explanation: Clienst with burns are hypermetabolic. This results in tachycardia, tachypnea, and elevated body temperature. These physiological norms in clients with burns make the diagnosis of sepsis more challenging. The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the client's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed, dry skin in unburned areas.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes? Miotics Nonsteroidal anti-inflammatory drugs (NSAIDs) Mydriatics Cycloplegics

Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.

A client with AIDS is having a recurrence of 10 to 12 loose stools a day. What medication may help this client with controlling the chronic diarrhea? Octreotide Rifaximin Bismuth subsalicylate Atropine diphenoxylate

Octreotide Explanation: Although many forms of diarrhea respond to treatment, it is not unusual for this condition to recur and become a chronic problem for the patient with HIV infection. Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to effectively manage chronic severe diarrhea.

The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the optic disc under magnification? Retinoscope Ophthalmoscope Tonometer Amsler grid

Ophthalmoscope Explanation: The nurse is correct to provide an ophthalmoscope to the surgeon for examination of theoptic disc. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula.

There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for: Tonometry. Ophthalmoscopy. Gonioscopy. Perimetry.

Ophthalmoscopy. Explanation: Four major types of examinations are used in glaucoma evaluation, diagnosis, and management: tonometry to measure the IOP, ophthalmoscopy to inspect the optic nerve, gonioscopy to examine the filtration angle of the anterior chamber, and perimetry to assess the visual fields.

What is located in the cochlea of the inner ear? Semicircular canals Labyrinth Vestibulocochlear nerve Organ of Corti

Organ of Corti Explanation: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea.

Nursing students are reviewing the structure and function of the ears in preparation for class the next day. The students demonstrate understanding of the information when they describe which of the following as a middle ear structure? Auricle Membranous labyrinth Ossicles Organ of Corti

Ossicles Explanation: The middle ear is composed of the tympanic membrane (eardrum) and ossicles. The auricle is an external ear structure. The membranous labyrinth and Organ of Corti are inner ear structures.

Which condition is characterized by the formation of abnormal spongy bone around the stapes? Otosclerosis Middle ear effusion Chronic otitis media Otitis externa

Otosclerosis Explanation: Otosclerosis is more common in females than males and is frequently hereditary. A middle ear effusion is denoted by fluid in the middle ear without evidence of infection. Chronic otitis media is defined as repeated episodes of acute otitis media, causing irreversible tissue damage and persistent tympanic membrane perforation. Otitis externa refers to inflammation of the external auditory canal.

You are teaching the daughter how to instill ear drops into her father's ear to remove impacted cerumen. What is a priority action to teach this woman? Insert the irrigating syringe deeply. Direct the flow of the ear drops toward the eardrum. Refrigerate before instillation. Place the container in warm water before instillation.

Place the container in warm water before instillation. Explanation: If irrigation or instillation of liquids is ordered, the nurse should warm the liquid to body temperature by placing the container in warm water. Cold or hot liquids cause dizziness, and the potential for injury exists if the liquid is hot. The nurse should avoid inserting the irrigating syringe too deeply so as not to close off the auditory canal. The nurse should direct the flow toward the roof of the canal, rather than the eardrum.

The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurence) in persons with AIDS? Cytomegalovirus Legionnaire's disease Mycobacterium tuberculosis Pneumocystis pneumonia

Pneumocystis pneumonia Explanation: Pneumocystic pneumonia (PCP) is one of the first and most common opportunistic infections associated with AIDS. It may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure.

A client is diagnosed with severe combined immunodficiency (SCID). What would the nurse expect to integrate into the client's plan of care? Administration of antifungal agents Preparation for bone marrow transplantation Administration of granulocyte colony-stimulating factors Preparation for a thymus graft

Preparation for bone marrow transplantation Explanation: For a client with severe combined immunodeficiency (SCID), the nurse would include in the plan of care preparing the client for a bone transplant. Antifungal agents are used to treat chronic mucocutaneous candidiasis. Granulocyte-stimulating factors would be used to treat immunodeficiency related to phagocytic dysfunction. A thymus graft would be used to treat DiGeorge syndrome.

Which terms refers to the progressive hearing loss associated with aging? Presbycusis Exostoses Otalgia Sensorineural hearing loss

Presbycusis Explanation: Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

Which condition refers to hearing loss associated with degenerative changes? Presbycusis Myopia Strabismus Presbyopia

Presbycusis Explanation: The term presbycusis refers to hearing loss associated with degenerative changes.

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate? Cataract Presbyopia Myopia Macular degeneration

Presbyopia Explanation: Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.

A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in? Primary infection Secondary infection Tertiary infection Latent infection

Primary infection Explanation: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, or stage 1. Initially, there is a period during which those who are HIV positive test negative on the HIV antibody blood test, although they are infected and highly infectious, because their viral loads are very high.

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder? Age younger than 40 years Hyperopia since age 20 years History of respiratory disease Prolonged use of corticosteroids

Prolonged use of corticosteroids Explanation: Risk factors associated with glaucoma include prolonged use of topical or systemic corticosteroids, older age, myopia, and a history of cardiovascular disease.

Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis? A) Pilocarpine B) Penicillin C) Ganciclovir D) Gentamicin

C Feedback: The surgically implanted sustained-release insert of ganciclovir enables higher concentrations of ganciclovir to reach the CMV retinitis. Pilocarpine is a muscarinic agent used in open-angle glaucoma. Gentamicin and penicillin are antibiotics that are not used to treat CMV retinitis.

A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign? A significant loss of central vision Diminished acuity Pain associated with a purulent discharge The presence of halos around lights

The presence of halos around lights Colored halos around lights is a classic symptom of acute-closure glaucoma.

Which is a major manifestation of Wiskott-Aldrich syndrome? Thrombocytopenia Ataxia Episodes of edema Bacterial infection

Thrombocytopenia Explanation: Major symptoms of Wiskott-Aldrich syndrome include thrombocytopenia, infections, and malignancies. Ataxia occurs with ataxia-telangiectasia. Episodes of edema in various body parts occur with angioneurotic edema. Bacterial infection occurs with hyperimmunoglobulinemia E syndrome.

Which of the following are antidepressants used in the treatment of AIDS? Select all that apply. Tofranil Norpramin Prozac Megace Mycelex

Tofranil Norpramin Prozac Explanation: Antidepressants such as Tofranil, Norpramin, and Prozac may be used, because these medications also alleviate the fatigue and lethargy that are associated with depression. Megace is an appetite stimulant. Mycelex is used for esophageal or oral candidiasis.

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse demonstrates a need for a review of transmission routes by identifying which body fluid as a means of transmission? Urine Semen Blood Breast milk

Urine Explanation: HIV is transmitted in body fluids that contain free virions and infected CD4+ T cells. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Urine is not a body fluid responsible for HIV transmission.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg Urine output of 20 ml/hour White pulmonary secretions Rectal temperature of 100.6° F (38° C)

Urine output of 20 ml/hour Explanation: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn? Rule of nines Use client's palm size Parkland formula Lund and Browder burns assessment

Use client's palm size Explanation: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns.

When caring for a client after ear surgery, what is an important aspect of nursing care? Assess social support. Feed small frequent meals to minimize nausea. Fit for a hearing aid. Validate client's feelings of discomfort.

Validate client's feelings of discomfort. Explanation: Validate client's feelings of discomfort. This measure promotes the nurse-client relationship and reassures the client that his or her needs are important.

The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications? A) Potassium-sparing diuretics B) Cholinergics C) Antibiotics D) Loop diuretics

B Feedback: Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not used in the management of glaucoma.

A nurse is auditing the care of a recently discharged patient and is appraising the patients care in light of Leiningers theory of Culture Care Diversity and Universality. Specifically, the nurse is looking for evidence that caregivers implemented professional actions and decisions that helped the patient achieve a beneficial or satisfying health outcome. What aspect of Leiningers theory is the nurse addressing? A) Cross-care accommodation B) Culture care restructuring C) Cultural reordering D) Patient modification

B Feedback: Culture care restructuring or repatterning refers to professional actions and decisions that help patients reorder, change, or modify their lifestyles toward new, different, or more beneficial health care patterns. The other listed options are not part of Leiningers theory.

A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Mnires disease. What question is it most important for the nurse to ask the patient in preparation for this test? A) Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? B) Do you currently take any tranquilizers or stimulants on a regular basis? C) Do you have a history of falls or problems with loss of balance? D) Do you have a history of either high or low blood pressure?

B Feedback: Electronystagmography measures changes in electrical potentials created by eye movements during induced nystagmus. Medications such as tranquilizers, stimulants, or antivertigo agents are withheld for 5 days before the test. Claustrophobia is not a significant concern associated with this test; rather, it is most often a concern for patients undergoing magnetic resonance imaging (MRI). Balance is impaired by Mnires disease; therefore, a patient history of balance problems is important, but is not relevant to test preparation. Hypertension or hypotension, while important health problems, should not be affected by this test.

An emergency department nurse is preparing to inspect and palpate the head and scalp of an older adult who experienced a fall. A member of which group would most likely consider this examination as a violation of norms? A) Jewish B) Asian American C) Islamic D) African American

B Feedback: For many Asian Americans, it is impolite to touch the patients head because the spirit is believed to reside in the head. Therefore, assessment of the head or evaluation of a head injury requires permission of the patient, or a family member if the patient is not able to give permission. This is not the case with the other listed groups.

The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years

B Feedback: Glaucoma has a family tendency and family members should be encouraged to undergo examinations at least once every 2 years to detect glaucoma early. Testing on a monthly basis is not necessary and excessive.

The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom? A) Hypertension with a wide pulse pressure B) Anhidrosis C) Copious diuresis D) Cheyne-Stokes respirations

B Feedback: Heat stroke is manifested by anhidrosis confusion, bizarre behavior, coma, elevated body temperature, hot dry skin, tachypnea, hypotension, and tachycardia. This health problem is not associated with anhidrosis or Cheyne-Stokes respirations.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue.

Epidermis and a portion of deeper dermis. Explanation: A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client? Endotracheal tube insertion Tracheostomy Escharotomy Ventilator assisted breathing

Escharotomy Explanation: In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharotomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? Classification by the appearance of blisters Identification by the destruction of the dermis and epidermis Not associated with edema formation Usually very painful because of exposed nerve endings

Identification by the destruction of the dermis and epidermis Explanation: Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation.

A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Ascites B) Rebound tenderness C) Changes in bowel sounds D) Muscular rigidity E) Copious diarrhea

B, C, D Feedback: Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

A patient with common variable immunodeficiency (CVID) is extremely fatigued and not feeling well. What lab test does the nurse anticipate the patient will have to detect a common development related to the disease? Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) Blood urea nitrogen (BUN) and creatinine Glucose level B12 level

B12 level Explanation: More than 50% of patients with CVID develop pernicious anemia, a condition in which the body cannot make enough red blood cells due to an inability to absorb vitamin B12.

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography? BUN and creatinine AST and ALT Hemoglobin and hematocrit Platelet count

BUN and creatinine Explanation: Angiography is done using fluorescein or indocyanine green as contrast agents. Fluorescein angiography is used to evaluate clinically significant macular edema, document macular capillary nonperfusion, and identify retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein. Prior to the angiography, the patient's blood urea nitrogen (BUN) and creatinine should be checked to ensure that the kidneys will excrete the contrast agent (Fischbach & Dunning, 2011).

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? BUN: 28 mg/dL K+: 5.0 mEq/L Na+: 145 mEq/L Ca: 9 mg/dL

BUN: 28 mg/dL Explanation: The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

The patient with glaucoma is usually started on the lowest dose of medication. Which of the following is the preferred initial topical medication? Beta-blockers Prostaglandins Carbonic anhydrase inhibitors Alpha-agonists

Beta-blockers Explanation: Because of their efficacy, minimal dosing (can be used once each day), and low cost, beta-blockers are the preferred initial topical medications. Beta-blockers decrease the production of aqueous humor, with a resultant decrease in IOP.

Following a serious thermal burn, which complication will the nurse take action to prevent first? Tissue hypoxia Infection Renal failure Hypovolemia

Hypovolemia Explanation: After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.

A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen? IV gamma globulin administration Platelet administration Factor VIII administration Thymus grafting

IV gamma globulin administration Explanation: Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation. It does not include platelet administration, factor VIII administration, or thymus grafting.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Do nothing until the chemical agent is identified. Irrigate the wounds with water. Wash the wounds with soap and water and apply a barrier cream. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

Which of the following are methods of removing foreign bodies from the ear? Select all that apply. Irrigation Suction Instrumentation Stapedectomy Stapedotomy

Irrigation Suction Instrumentation Explanation: The three standard methods for removing foreign bodies are the same as those for removing cerumen: irrigation, suction, and instrumentation. A stapedectomy involves removing the stapes superstructure and part of the footplate and inserting a tissue graft and a suitable prosthesis for treatment of otosclerosis.

A client comes to the eye clinic for a routine check-up. The client tells the nurse he thinks he is color blind. What screening test does the nurse know will be performed on this client to assess for color blindness? Rosenbaum Jaeger Ishihara Snellen

Ishihara Explanation: Color vision is assessed with Ishihara polychromatic plates. The client receives a series of cards on which the pattern of a number is embedded in a circle of colored dots. The numbers are in colors that color-blind persons commonly cannot see. Clients with normal vision readily identify the numbers. The Jaeger and the Rosenbaum test near vision while the Snellen tests far vision

Which practice utilizes herbal therapies? Biologically based therapy Energy therapy Mind-body interventions Alternative medical systems

Biologically based therapy Explanation: Biologically based therapy includes herbal therapies and special diet therapies. Therapeutic touch is a type of energy therapy. Mind-body interventions are techniques administered by trained practitioners or teachers, such as yoga and chiropractic. Alternative medical systems are a complete system of theory and practice that is different from conventional medicine.

Which of the following alternative therapies would include a strict low carbohydrate diet? Energy therapy Biologically based therapy Mind-body interventions Alternative medical systems

Biologically based therapy Explanation: Biologically-based therapies includes herbal therapies and special diet therapies. Therapeutic touch is a type of energy therapy. Alternative medical systems are a complete system of theory and practice that are different from conventional medicine. Alternative medical systems are a complete system of theory and practice that are different from conventional medicine.

Three major paradigms are used to explain the causes of disease and illness. Which three of the following are the paradigms? Choose all three. Biomedical or scientific view Naturalistic or holistic perspective Magico-religious view Geographic view Dynamic perspective

Biomedical or scientific view Naturalistic or holistic perspective Magico-religious view Explanation: Three major views, or paradigms, attempt to explain the causes of disease and illness: the biomedical or scientific view, the naturalistic or holistic view, and the magico-religious view. The geographic view and the dynamic perspective are not considered paradigms of causes of illness.

Which of the following is a disadvantage of surgical debridement? Scarring Bleeding Loss of function Contractures

Bleeding Explanation: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.

An ophthalmologist diagnoses a patient with myopia. The nurse explains that this type of impaired vision is a refractive error characterized by: Eyes that are shallow. A shorter depth to the eyeball. Blurred distance vision. Farsightedness.

Blurred distance vision. Explanation: People who have myopia are said to be nearsighted. They have deeper eyeballs; thus, the distant visual image focuses in front of, or short of, the retina. Myopic people experience blurred distance vision.

what 2 meds can cause irreversibe hearing loss?

aspirin, quinine

A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus? diarrhea hearing impairment blindness fatigue

blindness Explanation: CMV can infect the choroid and retinal layers of the eye, leading to blindness. It does not lead to hearing impairment. Fatigue and diarrhea may occur but are not as critical as blindness.

A client is color blind. The nurse understands that this client has a problem with: rods. cones. lens. aqueous humor.

cones. Explanation: Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.

During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response? cranial nerve VIII optic nerve cranial nerve VII facial nerve

cranial nerve VIII Explanation: Nerve receptors for balance are found both in the vestibule and semicircular canals. They transmit information about motion through the vestibular nerve, which joins with the cochlear nerve to form the eighth cranial nerve (formally called the auditory or acoustic nerve).

what is the most comon cause of retinal inflammation in patients with AIDS?

cytomegalovirus (CMV)

Which features should a nurse observe during an ophthalmic assessment? Select all that apply. external eye appearance pupil responses intraocular pressure visual acuity

external eye appearance pupil responses Explanation: During an ophthalmic assessment, the nurse should examine the external appearance of the eye and the pupil responses. Intraocular pressure and visual acuity involve a more complex examination and would be performed by a vision specialist.

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? face, neck, chest perineal hands, major joints All options are correct.

face, neck, chest Explanation: Burns of the face, neck, or chest have the potential to impair ventilation. face, neck, chest Explanation: Burns of the face, neck, or chest have the potential to impair ventilation.

Which of the following is the correct advice regarding food for a patient who underwent a cataract surgery? Eat soft, easily chewed foods. Eat spinach or collard greens two to four times per week. Eat red meat two to four times per week. Increase intake of vitamins A and C.

Eat soft, easily chewed foods. Explanation: The nurse should advise patients recovering from cataract surgery to eat soft, easily chewed foods until healing is complete to avoid tearing from excessive facial movements. Eating spinach or collard greens two to four times per week reduces the risk of macular degeneration and increasing the intake of vitamins A and C is essential for preventing cataracts; however, these have no implications on recovery from cataract surgery.

Therapeutic touch is an example of which alternative therapy? Energy therapy Alternative medical systems Manipulative and body-based methods Biologically based therapy

Energy therapy Explanation: Therapeutic touch is a type of energy therapy. Alternative medical systems are a complete system of theory and practice that is different from conventional medicine. Manipulative and body-based methods include chiropractic and reflexology. Biologically based therapy includes herbal therapies and special diet therapies.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Ensure a patent airway and that the patient is receiving 100% oxygen. Send the patient for a chest x-ray. Send the patient to the hyperbaric chamber. Draw labs for a chemistry panel.

Ensure a patent airway and that the patient is receiving 100% oxygen. Explanation: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

A client is diagnosed with a conductive hearing loss. When performing a Weber test, the nurse expects that this client will hear sound: on the affected side by bone conduction. on the unaffected side. longer through bone than air conduction. by neither air nor bone conduction.

on the affected side by bone conduction. Explanation: During the Weber test, which tests bone conduction, a client with a conductive hearing loss hears sound on the affected side by bone conduction. Hearing sound on the unaffected side by bone conduction occurs in sensorineural hearing loss. Also, during the Rinne test, the client with sensorineural hearing loss hears sound longer through air conduction than through bone conduction.

A nurse is obtaining a history from a new client with glaucoma. The client indicates having read about the diagnosis and understanding that this type of glaucoma is due to the degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the aqueous humor. The loss of absorption will lead to an increased resistance, and thus a chronic, painless buildup of pressure in the eye. Which type of glaucoma has the client described? open angle angle closure congenital secondary

open angle Explanation: The client described open-angle glaucoma. This type of glaucoma develops painlessly, and visual changes occur slowly. As the IOP rises, it causes edema of the cornea, atrophy of nerve fibers in the peripheral areas of the retina, and degeneration of the optic nerve

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: fluid resuscitation. infection. body image. pain management.

pain management. Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

Which tests tell the physician what the viral load is in a client with HIV/AIDS? Select all that apply. T4/T8 ratio polymerase chain reaction Western blot p24 antigen test ELISA test

polymerase chain reaction p24 antigen test Explanation: It is now possible to measure a person's viral load, the number of viral particles in the blood. The p24 antigen test and polymerase chain reaction test measure viral loads. The ELISA is a screening test for HIV. The Western blot is a diagnostic test for HIV. The T4/T8 ratio determines the status of T lymphocytes.

what foods should someone with Mnires disease avoid?

salty/sugary foods

surgical dbridement

shaving burned skin layers and early wound closure

exostoses

small, hard, bony protrusions found in the lower posterior bony portion of the ear canal; they usually occur bilaterally. They do not normally impact hearing and no treatments or nursing actions are usually necessary.

which cultures think direct eye contact is impolite?

some Asians, Native Americans, Indo-Chinese, Arabs, and Appalachians may consider direct eye contact impolite or aggressive, and they may avert their own eyes when talking with nurses and others whom they perceive to be in positions of authority

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: stasis. coagulation. hyperemia. hypotension.

stasis. Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones.

ossiculoplasty

surgical repair of the ossicle (middle ear bones) to restore hearing

Which antimicrobials is not commonly used to treat burns? tetracycline silver sulfadiazine (Silvadene) mafenide (Sulfamylon) silver nitrate (AgNO3) 0.5% solution

tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

extrapolation

the act of estimation by projecting known information

what is cultural blindness

the inability of people to recognize their own values, beliefs, and practices and those of others because of strong ethnocentric tendencies

Weber test

to detect sensorineural hearing loss. Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard.

A client is having a routine eye examination. The procedure being performed is done by using an instrument to indent or flatten the surface of the eye. This is known as ________ and it is routinely done to test for ________. tonometry; intraocular pressure retinoscopy; detached retina tonometry; macular degeneration retinoscopy; cataracts

tonometry; intraocular pressure Explanation: The procedure being performed is known as tonometry and it measures intraocular pressure

The term used to define the amount of virus in the body after the initial immune response subsides is viral set point. window period. primary infection stage. viral clearance rate.

viral set point. Explanation: The amount of virus in the body after the initial immune response subsides is referred to as the viral set point, which results in an equilibrium between HIV levels and the immune response that may be elicited. During the primary infection period, the window period occurs because a person is infected with HIV but negative on the HIV antibody blood test. The period from infection with HIV to the development of antibodies to HIV is known as the primary infection stage. The amount of virus in circulation and the number of infected cells equals the rate of viral clearance.

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? "An allograft is a temporary wound covering obtained from cadaver skin." "An allograft is a permanent wound covering taken from a donor site in your body." "An allograft is a temporary wound covering obtained from pig skin." "An allograft is an expensive sheet of skin obtained from a culture."

"An allograft is a temporary wound covering obtained from cadaver skin." Explanation: There are several different temporary and permanent coverings for burn wounds. Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the client. Xenografts consist of skin taken from animals (usually pigs). Therefore, the body's immune response will eventually reject them as a foreign substance.

A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? "You should take the drug with an antacid." "It doesn't matter if you take this drug with or without food." "Be sure to take this drug about 1/2 hour before or 2 hours after you eat." "When you take this drug, eat a high-fat meal immediately afterwards."

"Be sure to take this drug about 1/2 hour before or 2 hours after you eat." Explanation: Didanosine (Videx) should be taken 30 to 60 minutes before or 2 hours after meals. Other antiretroviral agents, such as abacavir, emtricitabine, or lamivudine can be taken without regard to meals. High-fat meals should be avoided when taking amprenavir. Atazanavir should be taken with food and not with antacids.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." "Try to ambulate independently after about 24 hours." "Shampoo your hair every day for 10 days to help prevent ear infection." "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." Explanation: The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry.

The nurse is working with a client who speaks limited English. Which of the following statements/questions would facilitate communication with this client? "First remove the dressing." "He takes his medicines, doesn't he?" "Don't do it that way." "Are you tired and in pain?"

"First remove the dressing." Explanation: Communication with patients with limited English-speaking abilities is facilitated when the nurse gives instructions in step-by-step sequence, avoids the use of contractions, has only one topic in a question, and usesg nouns repeatedly instead of pronouns.

The nurse identifies the nursing diagnosis of deficient knowledge related to a new hearing aid for a client. After teaching a client about caring for his new hearing aid, the nurse determines that the outcome has been achieved when the client states which of the following? "I need to wipe the ear mold daily with a moist washcloth." "I need to keep my ear canal clean and dry." "I should wash the receiver with soap and water once a week." "I should insert the ear mold when it is wet."

"I need to keep my ear canal clean and dry." Explanation: The client demonstrates understanding of the care of a hearing aid when stating the need to keep the ear canal clean and dry. The ear mold is the only part of the hearing aid that can be washed frequently, that is daily with soap and water. It should be allowed to dry completely before it is snapped into the receiver or inserted into the ear.

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? "I will wash my hands whenever I get home from work." "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will be sure to eat lots of fresh fruits and vegetables every day."

"I will be sure to eat lots of fresh fruits and vegetables every day." Explanation: The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.

A client is being prepared for a cochlear implant. Which client statement would alert the nurse to the need for additional teaching? "I'm going to be able to hear normally again." "I'll have a small incision behind my ear." "I'll wear an external transmitter and microphone." "I'll be able to hear medium and loud sounds for once."

"I'm going to be able to hear normally again." Explanation: A cochlear implant does not restore normal hearing. Rather, it helps the person detect medium to loud environmental sounds and conversation. A small receiver is implanted in the temporal bone through a postauricular incision with electrodes placed into the inner ear. The microphone and transmitter are worn on an external unit.

A client is diagnosed with a corneal abrasion and the nurse has administered proparacaine hydrochloride per orders to assess visual acuity. The client requests a prescription for this medication because it completely took away the pain. What is the best response by the nurse? "I will let the doctor know." "Prescriptions of this medication are generally not given because it can cause corneal problems." "It is standard for the doctor to write a prescription for this medication." "Usually we will send you home with this bottle and written instructions for administering the medication."

"Prescriptions of this medication are generally not given because it can cause corneal problems." Explanation: Proparacaine hydrochloride can cause corneal softening and other complications if overused. Clients with corneal abrasions or other painful eye disorders have a tendency to overuse the medication, thus leading to the complications. It would not be appropriate to give the bottle with written instructions, and it is not a standard prescription for eye disorders because of the complications from overuse. Telling the client that you will let the doctor know does not provide the education needed about this medication.

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member? "The client probably has a case of the flu and you should give acetaminophen." "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." "This is one of the side effects from antiretroviral therapy and will require changing the medication." "The client probably has pneumocystis pneumonia and will need to be evaluated by the health care provider."

"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." Explanation: A fungal infection, Cryptococcus neoformans is another common opportunistic infection among clients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures.

A client undergoing mastoid surgery asks the nurse about the pain following the surgery. Which response by the nurse is appropriate? "Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours." "The incisional pain usually last 3 weeks. The doctor will make sure you have enough pain medications." "Most client report a sharp shooting pain for 1 to 2 months following the surgery from the eustachian tube opening." "Usually there is a constant throbbing pain for the first week. Most client report no pain with the use of the pain medications."

"Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours." Explanation: The incisional pain from mastoid surgery is usually mild and controlled by prescribed pain medications. The client should be taking medications routinely the first 24 hours and as needed after 24 hours. Incisional pain usually does not last 3 weeks. The client may feel a sharp shooting pain when the eustachian tube is open for 2 to 3 weeks following surgery. A constant throbbing pain may indicate an infection and should be investigated.

A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement? "We can ask our family members to donate blood for stem cell harvesting." "The only treatment option is thymus gland transplantation." "We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling." "Hematopoietic stem cell transplantation cannot be performed until the age of 5 years."

"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling." Explanation: Treatment options for SCID include stem cell and bone marrow transplantation. Hematopoietic stem cell transplantation is the definitive therapy for SCID; the best outcome is achieved if the disease is recognized and treated early in life. The ideal donor is a human leukocyte antigen-identical sibling.

A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate? "You have some fluid that has collected in your middle ear but no infection." "It has resulted from the several recurrent episodes of acute otitis media you've had." "You have a common infection in one of the bones of your face." "Your eardrum has ruptured because of the extreme pressure in your middle ear from the infection."

"You have some fluid that has collected in your middle ear but no infection." Explanation: Serous otitis media involves fluid, without evidence of active infection, in the middle ear. Recurrent episodes of acute otitis media leads to chronic otitis media. An infection of the temporal bone (temporal bone osteomyelitis) is a serious but rare external ear infection called malignant external otitis. Rupturing of the eardrum refers to tympanic membrane perforation.

A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate? "Most clients need to use the drops for only about a few months." "If the drops don't work, surgery may be needed to cure your condition." "You'll need to use the drops for the rest of your life to control the glaucoma." "These drops are just the first step to make sure that your vision doesn't get worse."

"You'll need to use the drops for the rest of your life to control the glaucoma." Explanation: The client is demonstrating a lack of understanding about the condition and its treatment. The nurse needs to provide additional information to the client that the condition can be controlled but not cured. The statement about lifelong therapy would be most appropriate. Eye medications would most likely be needed for the long term, not just a few months. Surgery may be used in conjunction with medication therapy; however, neither method cures the condition. The goal of therapy is to reduce the intraocular pressure to prevent optic nerve damage. In some clients, medication may be all that is needed. In other cases, additional or combintation treatment with surgery or laser procedures may be necessary.

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)

A Feedback: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

The nurse is working with a parent whose child has just been diagnosed with selective immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child is going to die?" How should the nurse respond? "Your child may die without proper medication and treatment." "Selective immunoglobulin A deficiency is the term used to describe the early stages of AIDS." "If left untreated, selective immunoglobulin A deficiency can cause uncontrolled muscle movements with progressive neurologic deterioration." "Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract."

"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract." Explanation: Selective immunoglobulin A deficiency is congenital and characterized by a lack of immunoglobulin A, which predisposes clients to recurrent infections, adverse reactions to blood transfusions or immunoglobulin, autoimmune diseases, and hypothyroidism. There is no current treatment.

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? 90 g/day 110 g/day 180 g/day 270 g/day

180 g/day Explanation: Recommendations from recent literature advocate protein requirements of 1.5 to 2 g/kg/day (Saffle, Graves, & Cochran, 2012).

A patient is suspected of having glaucoma. What reading of IOP would demonstrate an increase resulting from optic nerve damage? 0 to 5 mm Hg 6 to 10 mm Hg 11 to 20 mm Hg 21 mm Hg or higher

21 mm Hg or higher Explanation: Intraocular pressure of greater than 21 mm Hg is a sign of primary open-angle glaucoma.

When preparing a teaching plan for a client diagnosed with otitis externa, the nurse instructs the client to avoid any water sport for which duration? 3 to 5 days 5 to 7 days 7 to 10 days 10 to 14 days

7 to 10 days Explanation: A client with otitis externa should refrain from any water sport for approximately 7 to 10 days to allow the canal to heal completely. Otherwise, recurrence is highly likely.

which religion doesn't allow eating pork?

7th day adventism, judaism and islam pork is prohibited Hinduism (ALL meat is prohibited)

Chapter 63: Eye The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the patient? A) Ensure adequate lighting in the patients room. B) Provide a dimly lit room to aid vision by limiting contrast. C) Carefully point out color differences for the patient. D) Carefully point out fine details for the patient.

A The nurse should provide adequate lighting in the patients room, as the rods are mainly responsible for night vision or vision in low light. If the patients rods are impaired, the patient will have difficulty seeing in dim light. The cones in the eyes provide best vision for bright light, color vision, and fine detail.

An infection control nurse is presenting an inservice reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? A) Agglutination B) Cellular immune response C) Humoral response D) Phagocytic immune response

A Feedback: Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link between two antigens. This takes place within the context of the humoral immune response, but is not synonymous with it. Cellular immune response, the immune systems third line of defense, involves the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the systems first line of defense, involving white blood cells that have the ability to ingest foreign particles.

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week

A Feedback: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV? A) Gay, bisexual, and other men who have sex with men B) Recreational drug users C) Blood transfusion recipients D) Health care providers

A Feedback: Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of the population but 61% of the new infections. This exceeds the incidence among drug users, health care workers, and transfusion recipients.

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding? A) This is a normal aging process of the eye. B) Glasses will minimize this phenomenon. C) The patient may be exhibiting signs of glaucoma. D) This may be a result of weakened ciliary muscles.

A Feedback: As the body ages, the perfect gel-like characteristics of the vitreous humor are gradually lost, and various cells and fibers cast shadows that the patient perceives as floaters. This is a normal aging process.

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response? A) Thats something that you and your doctor will likely talk about after your scars mature. B) That is something for you to talk to your doctor about because its not a nursing responsibility. C) I know this is really important to you, but you have to realize that no one can make you look like you used to. D) Unfortunately, its likely that you will have most of these scars for the rest of your life.

A Feedback: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the patients query. It is true that the patient will not realistically look like he or she used to, but this does not instill hope.

A 56-year-old woman who emigrated from Vietnam as an adult was admitted with a urinary tract infection, but has now developed urosepsis. The nurse is in the process of changing the patients plan of care accordingly. The nurse should consider what phenomenon that tends to occur in patients of all ages when they are ill? A) Tendency to regress in language skills B) Tendency to become more passive C) Tendency to become more involved in care D) Tendency to regress in age-appropriate behavior

A Feedback: During illness, patients of all ages tend to regress, and the regression often involves language skills. The other tendencies do not apply in this case.

A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera

A Feedback: Eye drops should be instilled into the conjunctival sac, where absorption can best take place, rather than distributed over the sclera. It is unnecessary to keep the eyes closed or to maintain a supine position after administration.

The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find? A) Flashing lights in the visual field B) Sudden eye pain C) Loss of color vision D) Colored halos around lights

A Feedback: Flashing lights in the visual field is a common symptom of retinal detachment. Patients may also report spots or floaters or the sensation of a curtain being pulled across the eye. Retinal detachment is not associated with eye pain, loss of color vision, or colored halos around lights.

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A Feedback: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

You are admitting a patient who is a recent immigrant from China and who has a diagnosis of adenocarcinoma. During the patients admission assessment, the patient speaks of her beliefs related to health care and indirectly references the yin/yang theory. Based on her cancer diagnosis and her yin/yang beliefs, which meal will the patient most likely order for lunch? A) Chicken noodle soup with crackers, fruit crisp, and hot tea B) Turkey sandwich, small tossed salad, and iced tea C) Chefs salad, bread, and water D) Fruit smoothie and granola bar

A Feedback: Foods are classified as cold (yin) and hot (yang) in the naturalistic or holistic perspective. In this theory, foods are transformed into yin and yang energy when metabolized by the body. Hot foods are eaten when a person has a cold illness such a cancer, headache, stomach cramps, and a cold. Based on this information, the patient would select chicken noodle soup with crackers, fruit crisp, and hot tea as these are hot foods. The other options are cold foods and are eaten when a patient has a hot illness such as a fever, rash, sore throat, ulcer, or infection.

A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patients complaint? A) These pains are an expected finding during the first few weeks of recovery. B) The patients complaints are suggestive of a postoperative infection. C) The patient may have experienced a spontaneous rupture of the tympanic membrane. D) The patients surgery may have been unsuccessful.

A Feedback: For 2 to 3 weeks after surgery, the patient may experience sharp, shooting pains intermittently as the eustachian tube opens and allows air to enter the middle ear. Constant, throbbing pain accompanied by fever may indicate infection and should be reported to the primary care provider. The patients pain does not suggest tympanic perforation or unsuccessful surgery.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patients frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patients frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patients frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.

A Feedback: Frozen extremities are usually placed in a 37C to 40C (98.6F to 104F) circulating bath for 30- to 40- minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

A Feedback: If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained? A) Frequently assess the patients skin integrity B) Inform the patient that he is likely to be charged with assault. C) Avoid interacting with the patient until the restraints are removed. D) Take the opportunity to perform a full physical assessment.

A Feedback: It is important to assess skin integrity when physical restraints are used. Criminal charges are not the responsibility of the nurse and the nurse should still interact with the patient. A full physical assessment, however, would likely be delayed until the patient is not combative

A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond? A) Overuse of these drops could soften your cornea and damage your eye. B) You could lose the peripheral vision in your eye if you used these drops too much. C) Im sorry, this medication is considered a controlled substance and patients cannot take it home. D) I know these drops will make your eye feel better, but I cant let you take them home.

A Feedback: Most patients are not allowed to take topical anesthetics home because of the risk of overuse. Patients with corneal abrasions and erosions experience severe pain and are often tempted to overuse topical anesthetic eye drops. Overuse of these drops results in softening of the cornea. Prolonged use of anesthetic drops can delay wound healing and can lead to permanent corneal opacification and scarring, resulting in visual loss. The nurse must explain the rationale for limiting the home use of these medications.

The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? A) External otitis is characterized by aural tenderness. B) External otitis is usually accompanied by a high fever. C) External otitis is usually related to an upper respiratory infection. D) External otitis can be prevented by using cotton-tipped applicators to clean the ear.

A Feedback: Patients with otitis externa usually exhibit pain, discharge from the external auditory canal, and aural tenderness. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external otitis so their use should be avoided.

You are planning an educational inservice for your nursing colleagues with the goal of fostering culturally competent care. What outcome should you prioritize when planning this education? A) Participants will acknowledge and adapt to diversity among their colleagues. B) Participants will develop insight into the characteristics of their own culture. C) Participants will provide equal care to all patients, regardless of their background. D) Participants will evaluate their colleagues levels of cultural awareness.

A Feedback: The concept of culturally competent care applies to health care institutions, which must develop culturally sensitive policies and provide a climate that fosters the provision of culturally competent care by nurses. Nurses must learn to acknowledge and adapt to diversity among their colleagues in the workplace. This is not necessarily dependent on nurses examining their own cultures. Because patients needs vary widely, care is not equal. Evaluating cultural awareness in others does not necessarily enhance ones own cultural competence.

A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care? A) Assessing for mouth droop and decreased lateral eye gaze B) Assessing for increased middle ear pressure and perforated ear drum C) Assessing for gradual onset of conductive hearing loss and nystagmus D) Assessing for scar tissue and cerumen obstructing the auditory canal

A Feedback: The facial nerve runs through the middle ear and the mastoid; therefore, there is risk of injuring this nerve during a mastoidectomy. When injury occurs, the patient may display mouth droop and decreased lateral gaze on the operative side. Scar tissue is a long-term complication of tympanoplasty and therefore would not be evident during the immediate postoperative period. Tympanic perforation is not a common complication of this surgery.

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A) The causative agent B) The patients preinjury health status C) The patients prognosis for recovery D) The circumstances of the accident

A Feedback: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The patients preinjury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs? A) A patient-controlled analgesia (PCA) system B) Oral opioids supplemented by NSAIDs C) Distraction and relaxation techniques supplemented by NSAIDs D) A combination of benzodiazepines and topical anesthetics

A Feedback: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this longterm discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the patient. The use of patient-controlled analgesia (PCA) gives control to the patient and achieves this goal. Patients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.

The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal? A) Encouraging the patient to gain a sense of control over his or her life B) Collecting sufficient evidence to secure a criminal conviction C) Helping the patient understand that this will not happen again D) Encouraging the patient to verbalize what happened during the assault

A Feedback: The goals of management are to provide support, to reduce the patients emotional trauma, and to gather available evidence for possible legal proceedings. All of the interventions are aimed at encouraging the patient to gain a sense of control over his or her life. The patients well-being should be considered a priority over criminal proceedings. No health professional can guarantee the patients future safety and having the patient verbalize the event is not a priority.

A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hypermotility C) Respiratory arrest D) Hypokalemia

A Feedback: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

The nurse is providing discharge education for a patient with a new diagnosis of Mnires disease. What food should the patient be instructed to limit or avoid? A) Sweet pickles B) Frozen yogurt C) Shellfish D) Red meat

A Feedback: The patient with Mnires disease should avoid foods high in salt and/or sugar; sweet pickles are high in both. Milk products are not contraindicated. Any type of meat, fish, or poultry is permitted, with the exception of canned or pickled varieties. In general, the patient with Mnires disease should avoid or limit canned and processed foods.

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

A Feedback: The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition

The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A) Respect the patients privacy during assessment. B) Shave all pubic hair for laboratory analysis. C) Place items for evidence in plastic bags. D) Bathe the patient before the examination.

A Feedback: The patients privacy and sensitivity must be respected, because the patient will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the patient before the examination would destroy or remove key evidence.

You are providing care for a patient who has a diagnosis of pneumonia attributed toStreptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process? A) Achieve SaO2 92% at all times. B) Auscultate chest q4h. C) Administer oral fluids q1h and PRN. D) Avoid overexertion at all times.

A Feedback: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.

A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact that her bone marrow is unable to produce a sufficient amount of what? A) Lymphocytes B) Cytoblasts C) Antibodies D) Capillaries

A Feedback: The white blood cells involved in immunity (including lymphocytes) are produced in the bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels

The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A) Maintain the irrigation fluid at a warm temperature. B) Instill short, sharp bursts of fluid into the ear canal. C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D) Have the patient stand during the procedure.

A Feedback: Warm water (never cold or hot) and gentle, not forceful, irrigation should be used to remove cerumen. Too forceful irrigation can cause perforation of the tympanic membrane, and ice water causes vomiting. Cerumen curettes should not be routinely used by the nurse. Special training is required to use a curette safely. It is unnecessary to have the patient stand during the procedure.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

A Feedback: Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patients blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

A Hypoglycemia can mimic alcohol intoxication and should be assessed in a patient suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The patient is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurses action is an example of which therapeutic communication technique? A) Informing B) Suggesting C) Expectation-setting D) Enlightening

A Informing involves providing information to the patient regarding his or her care. Suggesting is the presentation of an alternative idea for the patients consideration relative to problem solving. This action is not characterized as expectation-setting or enlightening.

A dietary modification for a patient with Ménière's disease would be: A decrease in sodium intake to 2,000 mg daily. Fluid restriction to 2 L/day. An increase in calcium to 1 g/day. An increase in vitamin C to 1.5 g/day.

A decrease in sodium intake to 2,000 mg daily. Explanation: Patients with Ménière's disease can be successfully treated by adhering to a low-sodium (2000 mg/day) diet, with no caffeine and alcohol.

The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis? The client being distressed in the mornings A progressive, bilateral loss of hearing A red and swollen ear drum The client describing a recent upper respiratory infection

A progressive, bilateral loss of hearing Explanation: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis.

A nurse is caring for clients from various cultural backgrounds. The care involved occasionally requires close physical contact. Which of the following are concepts for the nurse to consider interacting with diverse cultural clients? Choose all that apply. A wheelchair is considered part of the person in it. Sitting too close may be threatening to a client. Sitting too far away may signal disinterest to a client. It is best to be assertive if clients exhibit fear. Sitting too close is better than sitting too far away.

A wheelchair is considered part of the person in it. Sitting too close may be threatening to a client. Sitting too far away may signal disinterest to a client. Explanation: One client may perceive the nurse sitting close as an expression of warmth and caring; another client may perceive the same proximity as a threatening invasion of personal space. The wheelchair of a client is considered an extension of the person; therefore, the nurse should ask the person's permission before touching the wheelchair.

An autograft is harvested from a burn client under general anesthesia. What are the disadvantages to harvesting the client's own tissue? Select all that apply. All answers are correct. It compounds the client's pain because it creates a new wound. The donor site has the potential for scarring and atypical pigment changes. There is a potential for donor site infection. There is a delay in wound closure while waiting for the donor site to heal and be reharvested.

All answers are correct. Explanation: Harvesting a client's own tissue compounds the client's pain because it creates a new wound. The donor site has the potential for scarring and atypical pigment changes. There is a potential for donor site infection. There is a delay in wound closure while waiting for the donor site to heal and be reharvested.

The nurse is caring for an 86-year-old client with hearing impairment. The nurse is preparing to educate the client on the diagnosis and discharge plan. What action(s) should the nurse take when talking with the client? Select all that apply. Always face the client when talking. Ensure adequate lighting by standing in front of an uncovered window. Provide written instructions and information. Speak in a loud, high-pitched tone. Written material is written to an eighth-grade reading level.

Always face the client when talking. Provide written instructions and information. Explanation: The nurse, when talking, should always face the client who is hearing impaired. The nurse should provide written instructions and information based on a third-grade, not eighth-grade, reading level. Older adults lose the ability to hear high-pitched tones first; therefore speaking loudly in high-pitched tones will not help with communication for this client. Standing in front of a window can place a shadow on the nurse's face, not allowing the client to see the nurse's face or read lips.

Which feature should a nurse observe during an ophthalmic assessment? Internal eye function Appearance of the external eye Visual acuity Intraocular pressure

Appearance of the external eye Explanation: During an ophthalmic assessment, the nurse should examine the appearance of the external eye and the pupil responses in the client. A qualified examiner determines internal eye function, visual acuity, and intraocular pressure.

Which of the following measures can be used to cool a burn? Application of cool water Application of ice directly to burn Wrapping the person in ice Using cold soaks or dressings for at least 1 hour

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform? Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye Holds down the lower lid of the eye by applying pressure on the eyeball and the cheekbone Applies gentle pressure to the upper eyelid to keep the lid open while telling the client to gaze upward Applies firm pressure to the upper and lower eyelids at the outer edges to keep eyelids in approximation

Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye Explanation: Punctal occlusion is done by applying gentle pressure to the inner canthus of each eye for 1 to 2 minutes immediately after eye drops are instilled. The nurse does not apply pressure to the eyeball when administering medications. The lower eyelid is held down to expose the conjunctival sac. The other action described will not aid in the retention or absorption of medication.

In a client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Elevating the foot of the bed Hyperextending the client's palms Performing shoulder range-of-motion exercises

Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

A client who is blind is awaiting elective surgery. What should the nurse do to promote this client's control over their hospital environment? Ask the client where to store his or her self-care items. Keep personal care items where the nurse knows their location. Arrange the meal tray in a way that is easiest for the nurse to assist the client. Open all containers without prompting to be helpful.

Ask the client where to store his or her self-care items. Explanation: Ask the client's preference for where to store hygiene articles and other objects needed for self-care. Involving the client promotes his or her control over the environment. Personal care items should be kept in the same location at all times to provide the client with the ability to locate toiletries easily. At mealtime, describe where food is on the plate using the positions on the face of a clock. This measure assists the client to identify the location of food. Allow the client to open containers and offer help if needed. Having a choice facilitates independence.

High doses of which medication can produce bilateral tinnitus? Meclizine Aspirin Promethazine Dimenhydrinate

Aspirin Explanation: At high doses, aspirin toxicity can produce bilateral tinnitus. Meclizine and dimenhydrinate are used for nausea and vomiting related to motion sickness. Antiemetics, such as promethazine suppositories, help control nausea and vomiting and vertigo through an antihistamine effect.

A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action? Encourage the client to drink more fluids. Administer fluids 100 mL/hour IV. Assess blood urea nitrogen and creatinine. Assess liver function tests.

Assess blood urea nitrogen and creatinine. Explanation: Adverse effects associated with antiretroviral therapy include potential nephrotoxicity. Assessing blood urean nitrogen and creatinine for clients who have decreased urination is appropriate. The other answers will not assist the nurse in determining the client's problem, which should be assessed before intervention are administered.

A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse? Assess the tympanic membrane. Educate the client on the therapeutic effects of medications. Document the effectiveness of medications. Irrigate the ear.

Assess the tympanic membrane. Explanation: A client diagnosed with otitis media who feels sudden relief of pain and/or pressure should be assessed for a tympanic membrane rupture. Educating the client on the therapeutic effects of medications is appropriate for newly diagnosed otitis media, but it does not address the sudden disappearance of pain and pressure. Because the medication usually takes 48 to 72 hours to be effective, documenting the medication as effective would be inappropriate. It is not necessary to irrigate an ear with otitis media.

The nurse is instructing a client's family members on the most incapacitating symptom of Ménière's disease. Which nursing instruction associated with the symptom is most helpful? Assist the client when ambulating. Keep a bucket beside the bed. Ensure low lighting in the room. Sit in front of the client when speaking.

Assist the client when ambulating. Explanation: The most incapacitating symptom of Ménière's disease is vertigo. When the client is experiencing vertigo or dizziness, the gate is unsteady. Having a person assist the client when ambulating is most helpful in preventing falls. Keeping a bucket at the bedside is helpful if the client is experiencing nausea. Photophobia is not a main symptom of Ménière's disease. If the client experiences hearing loss, being able to see the client's lips may be helpful.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Attach a cardiac monitor Insert a Foley urinary catheter Assist with endotracheal intubation Administer inotropic drugs

Attach a cardiac monitor Explanation: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

A mother brings her daughter to the clinic for an evaluation because the child is complaining of ear pain. Which of the following would lead the nurse to suspect that the child is experiencing otitis externa and not otitis media? Fever Aural tenderness Bulging eardrum Ear drainage

Aural tenderness Explanation: A client with otitis externa typically experiences aural tenderness. This finding is usually absent in clients with otitis media. Fever and ear drainage may be present with either otitis externa or otitis media. A bulging eardrum would suggest otitis media.

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel

B Feedback: Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel. The liver is also injured frequently, but it is a solid organ.

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occured? Select all that apply. Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms Apply suctioning to clear the airway Re-set the ventilator rate as needed

Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms Explanation: It is important to remember that the right main bronchus is wider, shorter, and more vertical than the left. This physiologic difference may lead to inadvertent intubation of the right lung only. It is essential to listen to both sides of the chest for bilateral breath sounds, mark the correct endotracheal tube (ETT) placement at lip or nares, and monitor for high- and low-pressure alarms. Although suctioning the airway to remove secretions is an essential part of the nurse's responsibility when caring for a ventilated client, this action will not help the nurse determine if the tube has been placed only into the right lung only. The ventilator settings are determined by the client's primary health provider and any changes would require an order. These settings are specific to the client's individualized needs. Despite this, the re-seting the ventilator would not help determine incorrect placement of the endotracheal tube.

A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response? A) Perform mechanical dbridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.

B An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem and the nurse would not independently perform dbridement.

A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do? A) Call the physician and ask for the order to be confirmed. B) Follow the order because this position will help keep the retinal repair intact. C) Instruct the patient to maintain this position to prevent bleeding. D) Reposition the patient after the first dressing change.

B Feedback: For pneumatic retinopexy, postoperative positioning of the patient is critical because the injected bubble must float into a position overlying the area of detachment, providing consistent pressure to reattach the sensory retina. The patient must maintain a prone position that would allow the gas bubble to act as a tamponade for the retinal break. Patients and family members should be made aware of these special needs beforehand so that the patient can be made as comfortable as possible. It would be inappropriate to deviate from this order and there is no obvious need to confirm the order.

A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A) Apply a dressing saturated with chlorhexidine. B) Wash the bites with soap and water. C) Arrange for the patient to receive a hepatitis B vaccination. D) Assess the patients immunization history.

B After forensic evidence has been gathered, cleansing with soap and water is necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed. The patients immunization history does not directly influence the course of treatment and hepatitis B vaccination is not indicated. Chlorhexidine bandages are not recommended.

An elderly patient is admitted to your unit with a diagnosis of community-acquired pneumonia. During admission the patient states, I have a living will. What implication of this should the nurse recognize? A) This document is always honored, regardless of circumstances. B) This document specifies the patients wishes before hospitalization. C) This document that is binding for the duration of the patients life. D) This document has been drawn up by the patients family to determine DNR status.

B Feedback: A living will is one type of advance directive. In most situations, living wills are limited to situations in which the patients medical condition is deemed terminal. The other answers are incorrect because living wills are not always honored, they are not binding for the duration of the patients life, and they are not drawn up by the patients family.

A 54-year-old African American man has presented for a follow-up appointment shortly after being diagnosed with hypertension and being placed on an angiotensin-converting enzyme (ACE) inhibitor. The nurse takes the patients vital signs at the beginning of the appointment and obtains a blood pressure of 177/96 mm Hg. What factor should the nurse consider in light of the patients sustained high blood pressure? A) The patients culture may not prioritize taking a medication on a regular basis. B) Biologic variations may be influencing the effectiveness of the medication. C) The patients culture may not acknowledge symptom-free problems such as blood pressure. D) The patients diet may be negatively affecting the effectiveness of the medication.

B Feedback: Biologic variations can be highly significant, particularly in the use of antihypertensives in African American patients. This is more likely than culturally mediated views on medication adherence, symptom-free diseases, or diet.

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patients health history is most likely to be linked to the patients hearing deficit? A) Recent completion of radiation therapy for treatment of thyroid cancer B) Routine use of quinine for management of leg cramps C) Allergy to hair coloring and hair spray D) Previous perforation of the eardrum

B Feedback: Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing acuity. Radiation therapy for cancer should not affect hearing; however, hearing can be significantly compromised by chemotherapy. Allergy to hair products may be associated with otitis externa; however, it is not linked to hearing loss. An ear drum that perforates spontaneously due to the sudden drop in altitude associated with a high dive usually heals well and is not likely to become infected. Recurrent otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the middle ear.

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat

B Feedback: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing.

During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation? A) Ask the social worker to investigate alternative housing arrangements. B) Ask the social worker to investigate community support agencies. C) Encourage the patient to explore surgical corrections for the vision problem. D) Arrange for referral to a rehabilitation facility for vision training.

B Feedback: Managing low vision involves magnification and image enhancement through the use of low-vision aids and strategies and referrals to social services and community agencies serving those with visual impairment. Community agencies offer services to patients with low vision, which include training in independent living skills and a variety of assistive devices for vision enhancement, orientation, and mobility, preventing patients from needing to enter a nursing facility. A rehabilitation facility is generally not needed by the patients to learn to use the assistive devices or to gain a greater degree of independence. Surgical options may or may not be available to the patient.

The nurse is preparing the patient for mechanical dbridement and informs the patient that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from the viable tissue B) Removal of eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

B Feedback: Mechanical dbridementcan be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical dbridement can also be accomplished through the use of topical enzymatic dbridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural dbridement. Shaving the burned skin layers and early wound closure are examples of surgical dbridement.

A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this patient knows that the site of the injury will have an invasion of what? A) Interferons B) Phagocytic cells C) Apoptosis D) Cytokines

B Feedback: Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Apoptosis, or programmed cell death, is the bodys way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.

A nurse is working with a male patient who has recently received a diagnosis of human immunodeficiency virus (HIV). When performing patient education during discharge planning, what goal should the nurse emphasize most strongly? A) Encourage the patient to exercise within his limitations. B) Encourage the patient to adhere to his therapeutic regimen. C) Appraise the patients level of nutritional awareness. D) Encourage a disease-free state,

B Feedback: One of the goals of patient education is to encourage people to adhere to their therapeutic regimen. This is a very important goal because if patients do not adhere to their therapeutic regimen, they will not attain their optimal level of wellness. In this patients circumstances, this is likely a priority over exercise or nutrition, though these are important considerations. A disease-free state is not obtainable.

The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful? A) Otoscopy B) Audiometry C) Balance testing D) Culture and sensitivity testing of ear discharge

B Feedback: Ossiculoplasty is the surgical reconstruction of the middle ear bones to restore hearing. Consequently, results are assessed by testing hearing, not by visualizing the ear, testing balance, or culturing ear discharge.

A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis? A) Malleus B) Stapes C) Incus D) Tympanic membrane

B Feedback: Otosclerosis involves the stapes and is thought to result from the formation of new, abnormal bone, especially around the oval window, with resulting fixation of the stapes.

A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A) Monitoring fluid and electrolyte imbalances B) Providing education to the patient and family C) Treating infection D) Promoting thermoregulation

B Feedback: Patient and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the patient is still in the acute phase of burn recovery.

The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action? A) Placing the patient in a prone position B) Assisting the patient into a sitting position C) Instilling 15 mL of warm normal saline into one of the patients ears D) Assessing the patients baseline hearing by performing the whisper test

B Feedback: The Epley maneuver is performed by placing the patient in a sitting position, turning the head to a 45- degree angle on the affected side, and then quickly moving the patient to the supine position. Saline is not instilled into the ears and there is no need to assess hearing before the test.

An adult patient has requested a do not resuscitate (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patients son and daughter-in-law are strongly opposed to the patients request. What is the primary responsibility of the nurse in this situation? A) Perform a slow code until a decision is made. B) Honor the request of the patient. C) Contact a social worker or mediator to intervene. D) Temporarily withhold nursing care until the physician talks to the family.

B Feedback: The nurse must honor the patients wishes and continue to provide required nursing care. Discussing the matter with the physician may lead to further communication with the family, during which the family may reconsider their decision. It is not normally appropriate for the nurse to seek the assistance of a social worker or mediator. A slow code is considered unethical.

A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis

B Feedback: The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond? A) You know, you are getting older now and we change as we get older. B) The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry. C) There is a gradual thickening of the lens of the eye and it can limit the eyes ability for accommodation. D) The eye gets shorter, back to front, as we age and it changes how we see things.

C As a result of a loss of accommodative power in the lens with age, many adults require bifocals or other forms of visual correction. This is not attributable to a change in the shape of the ocular globe. The nurse should not dismiss or downplay the patients concerns.

A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A) Apply the new ointment without disturbing the existing layer of ointment. B) Apply the ointment using a sterile tongue depressor. C) Apply a layer of ointment approximately 1/16 inch thick. D) Gently irrigate the wound bed after applying the antibiotic ointment.

C After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16- inch thick using clean gloves. The wound would not be irrigated after application of new ointment.

A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? A) Audiometry B) Rinne test C) Whisper test D) Weber test

C Feedback: A general estimate of hearing can be made by assessing the patients ability to hear a whispered phrase or a ticking watch, testing one ear at a time. The Rinne and Weber tests distinguish sensorineural from conductive hearing loss. These tests, as well as audiometry, are not usually performed by a registered nurse in a general practice setting.

A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care teams most appropriate treatment? A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Referring to psychiatry

C Feedback: A patient who has swallowed an acidic substance, such as toilet bowl cleaner, may be given milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A psychiatric consult may be considered once the patient is physically stable and it is deemed appropriate by the physician. Syrup of ipecac is no longer used in clinical settings.

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area under any circumstances.

C Feedback: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.

A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C (104.2F). What would be the priority nursing action for this patient? A) Monitor cardiovascular effects. B) Administer antipyretics. C) Ensure airway and ventilation. D) Prevent seizure activity.

C Feedback: Although all of the listed actions may be necessary for this patients care, the priority is to establish a patent airway and adequate ventilation.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the patients IV fluid infusion. B) Report the patients early signs of acute kidney injury (AKI). C) Recognize that the patient is experiencing an expected onset of diuresis. D) Administer sodium chloride as ordered to compensate for this fluid loss.

C Feedback: As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

In a small, rural hospital the nurse is caring for a patient who speaks a language other than English. The nurse needs to use an interpreter to communicate but the hospital does not have access to an interpreter who speaks the patients language. When choosing another individual to interpret for this patient, what characteristic should the nurse prioritize? A) Interpreter should recognize the need to speak in a loud voice. B) Interpreter should be able to conduct the conversation quickly to avoid misinterpretation. C) Interpreter should be fluent in several dialects of the patients language. D) Interpreter should know that repetition must be avoided while interpreting.

C Feedback: Cultural needs should be considered when choosing an interpreter; for instance, fluency in varied dialects is beneficial. In choosing an interpreter, you do not want one who speaks in an excessively loud voice, conducts the conversation too quickly, or avoids repetition.

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) During waking hours for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury

C Feedback: Elastic pressure garments are worn continuously (i.e., 23 hours a day).

A nurse is planning the assessment of a patient who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among what group? A) Young adults B) Native Americans C) Women D) Hispanics

C Feedback: Many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones.

A nurse provides care in an inner-city hospital that serves a culturally diverse population. When attempting to foster positive and therapeutic nursepatient interactions, the nurse should recognize that these interactions are primarily dependent on what variable? A) The knowledge of patient tendencies during illness B) The nurses ability to work with a multicultural health care team C) The ability to understand and be understood D) Cultural diversity among the unit staff

C Feedback: Nursepatient interactions, as well as communications among members of a multicultural health care team, are dependent on the ability to understand and be understood. Nursepatient interactions are not dependent on the knowledge of patient tendencies during illness, the nurses ability to work with a multicultural health care team, or cultural diversity among the staff on the unit.

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of otitis externa? A) Tophi on the pinna and ear lobe B) Dark yellow cerumen in the external auditory canal C) Pain on manipulation of the auricle D) Air bubbles visible in the middle ear

C Feedback: Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear canal is a characteristic finding in patients with otitis externa. Tophi are deposits of generally painless uric acid crystals; they are a common physical assessment finding in patients diagnosed with gout. Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily indicate that inflammation is present. Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal.

A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patients discharge education? A) Expected changes in facial nerve function B) The need for audiometry testing every 6 months following recovery C) Safe use of analgesics and antivertiginous agents D) Appropriate use of OTC ear drops

C Feedback: Patients require instruction about medication therapy, such as analgesics and antivertiginous agents (e.g., antihistamines) prescribed for balance disturbance. OTC ear drops are not recommended and changes in facial nerve function are signs of a complication that needs to be addressed promptly. There is no need for serial audiometry testing.

The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patients health education? A) The need to limit exposure to bright light B) The need to maintain a low Fowlers position when removing the prosthesis C) The need to perform thorough hand hygiene before handling the prosthesis D) The need to apply antiviral ointment to the prosthesis daily

C Feedback: Proper hand hygiene must be observed before inserting and removing an ocular prosthesis. There is no need for a low Fowlers position or for limiting light exposure. Antiviral ointments are not routinely used.

An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients? A) A postlaryngectomy patient who is attempting to pull out his tracheostomy tube B) A patient in hypovolemic shock trying to remove the dressing over his central venous catheter C) A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode D) A patient with depression who has just tried to commit suicide and whose medications are not achieving adequate symptom control

C Feedback: Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more likely appropriate to apply restraints in these instances.

The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation

C Feedback: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound dbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A parent informs the nurse that immunizations are contrary to her religious beliefs, and she does not want her child to receive immunizations. The nurse proceeds to inform the parent that the child will be in grave danger of illness all her life and will not be allowed to start school unless she is immunized. The nurse also informs the parent that she had all of her own children vaccinated with no adverse effects. The nurses behavior is an example of what? A) Acculturation B) Cultural blindness C) Cultural imposition D) Cultural taboos

C Feedback: The nurses behavior is an example of cultural imposition, defined as the tendency to impose ones cultural beliefs, values, and patterns of behavior on a person from a different culture. Acculturation is the process by which members of a cultural group adapt to or learn how to take on the behaviors of another group. Cultural blindness is the inability of people to recognize their own values, beliefs, and practices and those of others because of strong ethnocentric tendencies. Cultural taboos are activities or behaviors that are avoided, forbidden, or prohibited by a particular cultural group.

You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations? A) Engage the patient in a process of health education. B) Administer opioid analgesics as ordered. C) Place the patient in a private, well-lit room. D) Provide television or a radio as therapeutic distraction

C Feedback: The patient should be placed in a quiet single room with lights on and in a calm nonstressful environment. TV and radio stimulation should be avoided. Analgesics are not normally necessary, and would potentially contribute to hallucinations. Health education would be inappropriate while the patient is experiencing acute withdrawal.

You are a community health nurse who provides care to a group of Hispanic people living in an area that is predominantly populated by Caucasian people. How would you characterize the Hispanic people in this community? A) An underclass B) A subgroup C) A minority D) An exception

C Feedback: The term minority refers to a group of people whose physical and cultural characteristics differ from the majority of people in a society. There are four generally identified minority groups: Blacks/African Americans, Hispanics, Asian/Pacific Islanders, and Native Americans. Such groups are not referred to as exceptions or underclasses. A subgroup is a division of a group that is in some way distinguished from the larger group.

A class of nursing students is in their first semester of nursing school. The instructor explains that one of the changes they will undergo while in nursing school is learning to think like a nurse. What is the most current model of this thinking process? A) Critical-thinking Model B) Nursing Process Model C) Clinical Judgment Model D) Active Practice Model

C Feedback: To depict the process of thinking like a nurse, Tanner (2006) developed a model known as the clinical judgment model.

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

C Feedback: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowlers position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.

C Feedback: When admitted for blunt trauma, patients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out.

A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery? A) Teaching the patient about options for eye prostheses B) Teaching the patient to estimate depth and distance with the use of one eye C) Assessing and addressing the patients emotional needs D) Teaching the patient about his post-discharge medication regimen

C Feedback: When surgical eye removal is unexpected, such as in severe ocular trauma, leaving no time for the patient and family to prepare for the loss, the nurses role in providing emotional support is crucial. In the short term, this is a priority over teaching regarding prostheses, medications, or vision adaptation.

An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B) Cholesteatomas are usually the result of metastasis from a distant tumor site. C) Cholesteatomas are often the result of chronic otitis media. D) Cholesteatomas, if left untreated, result in intractable neuropathic pain. E) Cholesteatomas usually must be removed surgically.

C, E Feedback: Cholesteatoma is a tumor of the external layer of the eardrum into the middle ear, often resulting from chronic otitis media. They usually do not cause pain; however, if treatment or surgery is delayed, they may burst or destroy the mastoid bone. They are not normally the result of metastasis and are not selflimiting.

Which is usually the most important consideration in the decision to initiate antiretroviral therapy? CD4+ counts HIV RNA Western blotting assay ELISA

CD4+ counts Explanation: The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.

Nursing students are reviewing information about the various types of primary immunodeficiencies. The students demonstrate understanding of the material when they identify which of the following as an example of a primary immunodeficiency involving B-lymphocyte dysfunction? CVID Ataxia-telengiectasia Wiskott-Aldrich syndrome Hyperimmunoglobulinemia E syndrome

CVID Explanation: CVID is an example of B-cell deficiency that results from a lack of differentiation of B cells into plasma cells. Ataxia-telengiectasia and Wiskott-Aldrich syndrome are examples of combined B- and T-lymphocyte dysfunction. Hyperimmunoglobulin E syndrome is an example of a primary immunodeficiency involving platelet dysfunction.

A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following? Streptococcus pneumonia Haemophilus influenzae Chlamydia trachomatis Staphylococcus aureus

Chlamydia trachomatis Explanation: Common organisms isolated are Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Two sexually transmitted agents associated with conjunctivitis are Chlamydia trachomatis and Neisseria gonorrhoeae

The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate? Conductive Mixed Central Sensorineural

Conductive Explanation: Conductive hearing loss occurs from an obstruction in the outer or middle ear such as from cerumen. Mixed hearing loss is a combination of conductive and sensorineural problems. Central hearing loss involves injury or damage to the nerves or the nuclei of the central nervous system. Sensorineural involves damage to the inner ear.

Which statement is consistent with acute otitis media? The infection usually lasts more than 6 weeks. It is a relatively uncommon childhood infection. It is usually caused by a fungal infection. Conductive hearing loss may occur.

Conductive hearing loss may occur. Explanation: Approximately three in four children experience an ear infection by the time they are 3 years of age. The infection usually lasts less than 6 weeks. Conductive hearing loss may occur due to a purulent exudate. Bacteria and viruses, not fungi, are the most common causes of otitis media.

During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as: Conductive. Functional. Mixed. Sensorineural.

Conductive. Explanation: A defect in the tympanic membrane or interruption of the ossicular chain disrupts normal air conduction, which results in a conductive hearing loss.

Loud, persistent noise has been found to have which of the following effects on the body? Select all that apply. Constriction of peripheral blood vessels Increased blood pressure Increased heart rate Decreased gastrointestinal motility Dilation of peripheral blood vessels

Constriction of peripheral blood vessels Increased blood pressure Increased heart rate Explanation: Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure and heart rate (because of increased secretion of adrenalin), and increased gastrointestinal activity, well as disturbed patterns of sleep.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? Elevate the leg on pillows and reassess the leg in 1 hour. Document the findings and instruct the client to report numbness of the extremity. Contact the primary care provider and prepare for an escharotomy. Apply an elastic stocking to the extremity and administer SQ heparin per order.

Contact the primary care provider and prepare for an escharotomy. Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

Nursing students are discussing transcultural nursing. One student asks about terms similar to this one. Which of the following terms could be used interchangeably with the term "transcultural nursing?" Choose all that apply. Cross-cultural nursing Acculturation nursing Intercultural nursing Multicultural nursing Cultural-blindness nursing

Cross-cultural nursing Intercultural nursing Multicultural nursing Explanation: Transcultural nursing, a term sometimes used interchangeably with cross-cultural, intercultural, or multicultural nursing, refers to research-focused practice that focuses on client-centered, culturally competent nursing.

The nurse observes unlicensed staff insisting that he will bathe a female client, including her perineum, even though the client's caregivers request that a female aide perform this task. The nurse realizes that the unlicensed caregiver is exhibiting which characteristic? Cultural imposition Cultural blindness Cultural taboos Acculturation

Cultural imposition Explanation: Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person or people from a different culture. Cultural blindness is the inability of people to recognize their own values, beliefs, and practices and those of others because of strong ethnocentric tendencies. Acculturation is the process by which members of cultural group adapt to or learn to take on the behaviors of another group. Cultural taboos are activities or behaviors that are avoided, forbidden, or prohibited by a particular cultural group.

What type of medication would the nurse use in combination with mydriatics to dilate the patient's pupil? Anti-infectives Corticosteroids Cycloplegics NSAIDs

Cycloplegics Explanation: Mydriasis, or pupil dilation, is the main objective of the administration of mydriatics and cycloplegics (Table 63-3). These two types of medications function differently and are used in combination to achieve the maximal dilation that is needed during surgery and fundus examinations to give the ophthalmologist a better view of the internal eye structures.

Which microorganism is known to cause retinitis in people with HIV/AIDS? Cytomegalovirus Cryptococcus neoformans Mycobacterium avium Pneumocystis carinii

Cytomegalovirus Explanation: Cytomegalovirus is a species-specific herpes virus. C. neoformans is a fungus that causes an opportunistic infection in clients with HIV/AIDS. M. avium is an acid-fast bacillus that commonly causes a respiratory illness. P. carinii is an organism that is thought to be protozoan, but believed to be a fungus based on its structure.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

D Feedback: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? A) Slight morning discharge from the eye B) Any appearance of redness of the eye C) A scratchy feeling in the eye D) A new floater in vision

D Feedback: Cataract surgery increases the risk of retinal detachment and the patient must be instructed to notify the surgeon of new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days after surgery.

The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patients plan of care? A) The nurse should perform the Rinne and Weber tests. B) The nurse should arrange for audiometry testing as soon as possible. C) The nurse should collaborate with the pharmacist to assess for potential ototoxic medications. D) No specific assessments or interventions are necessary to addressing exostoses.

D Feedback: Exostoses are small, hard, bony protrusions found in the lower posterior bony portion of the ear canal; they usually occur bilaterally. They do not normally impact hearing and no treatments or nursing actions are usually necessary.

A patient with a sudden onset of hearing loss tells the nurse that he would like to begin using hearing aids. The nurse understands that the health professional dispensing hearing aids would have what responsibility? A) Test the patients hearing promptly. B) Perform an otoscopy. C) Measure the width of the patients ear canal. D) Refer the patient to his primary care physician.

D Feedback: Health care professionals who dispense hearing aids are required to refer prospective users to a physician if the patient has sudden or rapidly progressive hearing loss. This would be a health priority over other forms of assessment, due to the possible presence of a pathologic process.

A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? A) Ossiculoplasty B) Insertion of a cochlear implant C) Stapedectomy D) Insertion of a ventilation tube

D Feedback: If AOM recurs and there is no contraindication, a ventilating, or pressure-equalizing, tube may be inserted. The ventilating tube, which temporarily takes the place of the eustachian tube in equalizing pressure, is retained for 6 to 18 months. Ossiculoplasty is not used to treat AOM and stapedectomy is performed to treat otosclerosis. Cochlear implants are used to treat sensorineural hearing loss.

A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do? A) Stand him up and perform the abdominal thrust maneuver from behind. B) Lay him down, straddle him, and perform the abdominal thrust maneuver. C) Leave him to get assistance. D) Stay with him and encourage him, but not intervene at this time.

D Feedback: If the patient is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the patient standing. If the patient is unconscious, the nurse should lay the patient down. A nurse should never leave a choking patient alone.

A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? A) Refer the family to psychiatry in order to provide them with support. B) Explore the causes of the patients suicide attempt with the family. C) Encourage the family to participate in the bedside care of the patient. D) Ensure that the family receives appropriate crisis intervention services.

D Feedback: It is essential that family crisis intervention services are available for families of ED patients. It would be inappropriate and insensitive to explore causes of the patients suicide attempt with the family. Family participation in bedside care is often impractical in the ED setting. Psychiatry is not the normal source of psychosocial support and crisis intervention.

A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be? A) Ossiculitis B) Mnires disease C) Ototoxicity D) Labyrinthitis

D Feedback: Labyrinthitis is characterized by a sudden onset of incapacitating vertigo, usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus. None of the other listed diagnosis is characterized by a rapid onset of symptoms.

A nurse who provides care on a busy medical unit is aware that his own beliefs do not always coincide with the beliefs of patients from some cultural backgrounds. What aspects of patient care may be most influenced by diverse cultural perspectives? A) Pharmacokinetics and pharmacodynamics B) Monitoring fluid balance C) Monitoring food intake D) Obtaining informed consent

D Feedback: Many aspects of care may be influenced by the diverse cultural perspectives held by health care providers, patients, families, or significant others. One example is the issue of informed consent and full disclosure. The other aspects of care can also be influenced by cultural differences, but most often to a lesser degree.

Computed tomography of a 72-year-old woman reveals lung cancer with metastasis to the liver. The patients son has been adamant that any bad news be withheld from his in order to protect her from stress, stating that this is a priority in his culture. How should the nurse and the other members of the care team best respond? A) Explain to the son the teams ethical obligation to inform the patient. B) Refer the family to social work. C) Have a nurse or physician from the patients culture make contact with her and her son. D) Speak with the son to explore his rationale and attempt to reach a consensus.

D Feedback: Nurses must promote open dialogue and work with patients, families, physicians, and other health care providers to reach the culturally appropriate solution for the individual patient. A referral to social work is not a sufficient response and enlisting a caregiver from the same culture may not be ethical or effective.

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A) Rinsing the ears with normal saline after swimming B) Avoiding loud environmental noises C) Instilling antibiotic ointments on a regular basis D) Avoiding the use of cotton swabs

D Feedback: Nurses should instruct patients not to clean the external auditory canal with cotton-tipped applicators and to avoid events that traumatize the external canal such as scratching the canal with the fingernail or other objects. Environmental noise should be avoided, but this does not address the risk for ear infection. Routine use of antibiotics is not encouraged and rinsing the ears after swimming is not recommended.

A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A) Risk factors for postoperative cytomegalovirus (CMV) B) Compensating for vision loss for the next several weeks C) Non-pharmacologic pain management strategies D) Signs and symptoms of increased intraocular pressure

D Feedback: Patients must be educated about the signs and symptoms of complications, particularly of increasing IOP and postoperative infection. CMV is not a typical complication and the patient should not expect vision loss. Vitreoretinal procedures are not associated with high levels of pain.

Agency policies are important to achieve culturally competent care. When reviewing a hospitals current policy framework, which of the following actions has the potential to improve the overall level of culture competence? A) Reducing the institutions dependence on English for communication B) Promoting members of minority groups to higher profile positions C) Eliminating written information from staff members identification badges D) Creating greater flexibility in visiting hours

D Feedback: Policies that promote culturally competent care establish flexible regulations pertaining to visitors, such as the number, frequency, and length of visits. Eliminating written information from staff members identification badges is unnecessary and of little benefit. Cultural competence does not require a reduction in the use of English. Promoting members of minority groups to higher profile positions on the sole basis of ethnicity would be unethical.

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A) Assess the patient for signs of electrolyte imbalances. B) Administer fluids as ordered. C) Assess the risk for injury recurrence. D) Assess the patients psychosocial state.

D Feedback: Recovery from burns can be psychologically challenging; the nurses assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing? A) Reorganization phase B) Denial phase C) Heightened anxiety phase D) Acute disorganization phase

D Feedback: The acute disorganization phase may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered. These varied responses to the assault are not associated with a denial, heightened anxiety, or reorganization phase.

During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise? A) Good Samaritan Act B) Nursing Interventions Classification (NIC) C) Patient Self-Determination Act D) ANA Code of Ethics

D Feedback: The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated

Touch, to a great degree, is culturally determined. When providing care for a patient who belongs to a Hispanic culture, which of the following may be considered inappropriate in a health care setting? A) Grandmothers helping in the care of pediatric patients. B) Patients asking questions of health care providers. C) Health care information being given to a female member of the family. D) Males participating in health care activities.

D Feedback: The meaning people associate with touching is culturally determined to a great degree. In some cultures (e.g., Hispanic, Arab), male health care providers may be prohibited from touching or examining certain parts of the female body. Similarly, it may be inappropriate for females to care for males. In the Hispanic culture, grandmothers often care for pediatric patients; the female of the family is often held responsible for the familys health care and health care information. Males of the Hispanic culture generally do not participate in health care activities when a member of their family is ill. There is no prohibition against asking questions.

A nurse is assesing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment? Severe joint pain Lymphedema of the lower extremities Deep purple cutaneous lesions Venous stasis and phlebitis formation

Deep purple cutaneous lesions Explanation: Localized cutaneous lesions may be the first manifestation of this HIV-related malignancy, which appears in 90% of clients as immune function deteriorates. Other symptoms develop over time as the lesions increase in size and spread to other locations.

Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, Im terrified of getting AIDS from a blood transfusion. How can the nurse best address the patients concerns? A) All the donated blood in the United States is treated with antiretroviral medications before it is used. B) That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility. C) HIV was eradicated from the US blood supply in the early 2000s. D) The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low.

D Feedback: The patient can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood.

An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention? A) Prompt administration of an antidote B) Gastric lavage C) Administration of activated charcoal D) Helping the patient drink large amounts of water

D Feedback: The patient who has ingested a corrosive poison, such as bleach, is given water or milk to drink for dilution. Gastric lavage is not used to treat ingestion of corrosives and activated charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.

The physician has recommended an amniocentesis for an 18-year-old primiparous woman. The patient is 34 weeks gestation and does not want this procedure. The physician is insistent the patient have the procedure. The physician arranges for the amniocentesis to be performed. The nurse should recognize that the physician is in violation of what ethical principle? A) Veracity B) Beneficence C) Nonmaleficence D) Autonomy

D Feedback: The principle of autonomy specifies that individuals have the ability to make a choice free from external constraints. The physicians actions in this case violate this principle. This action may or may not violate the principle of beneficence. Veracity centers on truth-telling and nonmaleficence is avoiding the infliction of harm.

In planning the nursing care of a patient who lives with chronic pain, the nurse has included the intervention of therapeutic touch. When categorizing this particular complementary therapy, the nurse should identify it as which of the following? A) A biologically based therapy B) A mind-body intervention C) A manipulative and body-based method therapy D) An energy therapy

D Feedback: Therapeutic touch is an example of an energy therapy. Biologically based therapies include herbal therapies, special diet therapies, orthomolecular therapies, and biologic therapies. Mind-body interventions include meditation, dance, music, art therapy, prayer, and mental healing. Manipulative and body-based methods include chiropractic, massage therapy, osteopathic manipulation, and reflexology. The other options are incorrect because they are not examples of energy therapy.

A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patients bladder is distended. What is the nurses most appropriate action? A) Withhold fluids from the patient. B) Perform intermittent urinary catheterization. C) Insert a narrow-gauge indwelling urinary catheter. D) Await orders following the urologists assessment.

D Feedback: Urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required. The nurse would withhold fluids, but urologic assessment is the priority.

A care conference has been organized for a patient with complex medical and psychosocial needs. When applying the principles of critical thinking to this patients care planning, the nurse should most exemplify what characteristic? A) Willingness to observe behaviors B) A desire to utilize the nursing scope of practice fully C) An ability to base decisions on what has happened in the past D) Openness to various viewpoints

D Feedback: Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation. An emphasis on the past, willingness to observe behaviors, and a desire to utilize the nursing scope of practice fully are not central characteristics of critical thinkers.

On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis? A) Acoustic tumor B) Cholesteatoma C) Facial nerve neuroma D) Glomus tympanicum

D In the case of glomus tympanicum, a red blemish on or behind the tympanic membrane is seen on otoscopy. This assessment finding is not associated with an acoustic tumor, facial nerve neuroma, or cholesteatoma.

A nurse practitioner explains to a patient recently diagnosed with noise-induced hearing loss that the basic altered physiology in the ear is the result of: Damage to the hair cells inside the cochlea. Stenosis of the semicircular canals. Hardening of the tympanic membrane. Malfunctioning of the incus and the staples.

Damage to the hair cells inside the cochlea. Explanation: About 25% of all Americans who have a hearing loss have noise-induced hearing loss caused by damage to the hair cells found inside the cochlea. These cells convert sound energy into electrical signals that travel to the brain. Once damaged, they cannot be repaired.

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? Deep partial thickness Superficial partial thickness Full thickness Superficial

Deep partial thickness Explanation: A deep, partial-thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.

During a routine physical examination, the nurse practitioner notes that a 72-year-old patient has a significant loss of ability to discriminate words. The patient also states that he has noticed that he has trouble hearing high-frequency sounds. The nurse suspects that the patient has an age-related change in his ears known as: Cerumen hardening. Alterations in the vestibulospinal reflex. Thickening of the eardrum. Degeneration of the organ of Corti.

Degeneration of the organ of Corti. Explanation: Degeneration of the organ of Corti causes a decreased ability to discriminate high frequencies or to interpret consonant sounds. Refer to Table 48-2 in the text. Alterations in the vestibulospinal reflex affect balance and gait

As part of HAART therapy, a client is prescribed a non-nucleoside reverse transcriptase inhibitor (NNRTI). What would be an example of a drug from this class? Select all that apply. Abacavir Delavirdine Amprenavir Efavirenz Stavudine

Delavirdine Efavirenz Explanation: Examples of NNRTIs are delavirdine and efavirenz. Abacavir and stavudine are nucleoside reverse transcriptase inhibitors (NRTIs). Amprenavir is a protease inhibitor.

The nurse is preparing a presentation for a group of older adults on the topic of open-angle glaucoma. Which symptoms would be included as indications of open-angle glaucoma? Select all that apply. Difficulty adjusting eyes in low lighting Halos around lights Blurred vision Decreasing peripheral vision Bright flashing lights Severe pain

Difficulty adjusting eyes in low lighting Halos around lights Blurred vision Decreasing peripheral vision Explanation: Decreased peripheral vision, difficulty adjusting eyes in low lighting, halos, and blurred vision are typical symptoms of open-angle glaucoma. Bright flashes of light may be an indication of retinal detachment. Severe pain is usually associated with angle-closure glaucoma or eye trauma.

There are many ethical issues in the care of clients with HIV or HIV/AIDS. What is an ethical issue healthcare providers deal with when caring for clients with HIV/AIDS? Sharing the diagnosis with a support group Caring for a client who can kill other people Disclosure of the client's condition Caring for a client with an infectious terminal disease

Disclosure of the client's condition Explanation: Despite HIV-specific confidentiality laws, clients infected with AIDS fear that disclosure of their condition will affect employment, health insurance coverage, and even housing. Since healthcare providers do not share a client's diagnosis with a support group, option A is incorrect. Caring for a client with an infectious terminal illness that can be transmitted to other people is a concern for healthcare providers but it is not an ethical issue.

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Swimming in a lake Diving in an ocean Running a race in hot humid weather Working in a chemical plant

Diving in an ocean Explanation: Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.

Health teaching for a patient who suffers from motion sickness would include recommending the use of which one of the following over-the-counter drugs? Scopolamine Phenergan Dramamine Ephedrine

Dramamine Explanation: Scopolamine and Phenergan are popular anticholinergics; ephedrine is a popular sympathomimetic. Dramamine and Antivert are over-the-counter antihistamines that act by blocking the conduction of the vestibular pathway of the inner ear.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Full-thickness Superficial Superficial partial-thickness Deep partial-thickness

Full-thickness Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Anemia Gastric ulcers Hyperthyroidism Cardiac arrest

Gastric ulcers Explanation: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

The nurse is reviewing the medical record of a client who is positive for human immunodeficiency virus (HIV). The nurse notes that the client is classified as HIV asymptomatic based on which CD4+ T lymphocyte count? Less than 200/mm3 Between 200 to 350/mm3 Between 350 to 499/mm3 Greater than 500/mm3

Greater than 500/mm3 Explanation: A client is classified as HIV asymptomatic when the CD4+ T lymphocyte count is greater than 500/mm3. A person is considered HIV symptomatic when the CD4+ count is 200 to 499/mm3. A person is considered to have aquired immunodeficiency syndrome (AIDS) when the CD4+ count is less than 200/mm3.

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic? means of transmission HIV-1 is more prevalent than HIV-2 subtypes the fact that it is a mutated virus originally thought to be bovine in nature cure rate

HIV-1 is more prevalent than HIV-2 subtypes Explanation: Two HIV subtypes have been identified: HIV-1 and HIV-2. HIV-1 mutates easily and frequently, producing multiple substrains that are identified by letters from A through O. HIV-2 is less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer. HIV-1 is more prevalent in the United States and in the rest of the world. Western Africa is the primary site of infection with HIV-2. There is no cure for HIV/AIDS; hence, no cure rate. The virus is thought to be a mutation of a simian virus. Transmission of the virus is not a characteristic.

The nurse should monitor for which manifestation in a client who has had LASIK surgery? Excessive tearing Cataract formation Halos and glare Stye formation

Halos and glare Explanation: After LASIK surgery, symptoms of central islands and decentered ablations can occur that include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.

The nurse should monitor for which manifestation in a client who has undergone LASIK? Excessive tearing Cataract formation Halos and glare Stye formation

Halos and glare Explanation: Symptoms of central islands and decentered ablations can occur after LASIK surgery; these include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.

Which condition is an early manifestation of HIV encephalopathy? Hyperreflexia Headache Vacant stare Hallucinations

Headache Explanation: Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.

Infants with DiGeorge syndrome have which type of endocrine disorder? Hypothyroidism Hyperthyroidism Hypoparathyroidism Hyperparathyroidism

Hypoparathyroidism Explanation: Infants born with DiGeorge syndrome have hypoparathyroidism with resultant hypocalcemia resistant to standard therapy. The other endocrine disorders do not occur in DiGeorge syndrome.

Which phase of the psychological reaction to rape is characterized by fear and flashbacks? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase

Heightened anxiety phase Explanation: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.

Which of the following indicates that a client with HIV has developed AIDS? Severe fatigue at night Pain on standing and walking Weight loss of 10 lb over 3 months Herpes simplex ulcer persisting for 2 months

Herpes simplex ulcer persisting for 2 months Explanation: A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex.

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? Autografts Heterografts Homografts Xenografts

Homografts Explanation: Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.

A newborn has been diagnosed with DiGeorge syndrome. Which of the following would the nurse least likely expect to assess? Hypercalcemia Congenital heart defect Cleft palate Hypoparathyroidism

Hypercalcemia Explanation: Infants born with DiGeorge syndrome have hypoparathyroidism with resultant hypocalcemia resistant to standard therapy, congenital heart disease, cleft palate and lip, dysmorphic facial features, and possibly renal abnormalities.

An infant that is 10 hours postdelivery is observed to have tetanic contraHIVctions. What symptom does the nurse recognize can indicate DiGeorge syndrome? Chronic diarrhea Hypocalcemia Neutropenia Pernicious anemia

Hypocalcemia Explanation: Thymic hypoplasia, also known as DiGeorge syndrome, is associated with recurrent infections, hypoparathyroidism, hypocalcemia, tetany, convulsions, congenital heart disease, possible renal abnormalities, and abnormal facies.

Which of the following is a lack of one or more of the five immunoglobulins? Hypogammaglobulinemia Agammaglobulinemia Panhypoglobulinemia Telangiectasia

Hypogammaglobulinemia Explanation: Hypogammaglobulinemia is a lack of one or more of the five immunoglobulins. Agammaglobulinemia is a disorder marked by an almost complete lack of immunoglobulins or antibodies. Panhypoglobulinemia is a general lack of immunoglobulins in the blood. Telangiectasia are vascular lesions caused by dilated blood vessels.

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find? Urine specific gravity of 1.010 Hypernatremia Hypokalemia Proteinuria

Hypokalemia Explanation: Electrolyte imbalances such as decreased sodium, potassium, calcium, magnesium, and chloride typically result from profuse diarrhea. A urine specific gravity of 1.010 would indicate dilute urine. The client with severe diarrhea most likely would be dehydrated, leading to a high urine specific gravity. Proteinuria may suggest renal dysfunction and would not be associated with severe diarrhea unless the client was developing renal failure.

The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis? Identification of opacities on the lens Identification of white circle around the cornea Identification of yellowish aging spot on the retina Identification of redness of the sclera

Identification of opacities on the lens Explanation: The client states an increased glare and changes in color perception, which indicates a cataract. Identification of opacities on the lens confirms that diagnosis. A white circle around the cornea and a yellowish aging spot are also symptoms of aging but with different symptoms. Redness of the sclera indicates irritation.

Loud, persistent noise has what effect on the body? Dilation of peripheral blood vessels Increased blood pressure Decreased heart rate Decreased gastrointestinal activity

Increased blood pressure Explanation: Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure, increased heart rate, and increased gastrointestinal motility.

What does the nurse understand will result if the patient has a deficiency in the normal level of complement? Increased susceptibility to infection Decrease in vascularity to the extremities Development of congestive heart failure Risk of stroke

Increased susceptibility to infection Explanation: The complement system is an integral part of the immune system, and deficiencies in normal levels of complement result in increased susceptibility to infectious diseases and immune-mediated disorders.

A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear? Instillation of mineral oil Instillation of carbamide peroxide Instillation of hot water Use of a small forceps

Instillation of mineral oil Explanation: Mineral oil is instilled into the ear to smother an insect. Carbamide peroxide is used to soften dried cerumen, and small forceps are used to remove solid objects. Hot liquids cause dizziness and should not be instilled in the ear.

A nursing student is learning how to adequately use an otoscope to examine the ear. What method should the instructor educate the student to use when examining with an otoscope? Otoscope should be held in the examiner's right hand, in a pencil-hold position, with the examiner's hand braced against the patient's face. Otoscope should be held in the examiner's left hand, with a full hand grasp to be able to guide the scope into the internal ear. Otoscope should be held in the examiner's dominant hand, with a full hand grasp to be able to guide the scope into the internal ear. Otoscope should be held in the examiner's left hand, in a pencil-hold position, with the examiner's hand braced against the patient's face.

Otoscope should be held in the examiner's right hand, in a pencil-hold position, with the examiner's hand braced against the patient's face. Explanation: To examine the external auditory canal and tympanic membrane, the otoscope should be held in the examiner's right hand, in a pencil-hold position, with the examiner's hand braced against the patient's face (Fig. 64-4). This position prevents the examiner from inserting the otoscope too far into the external canal.

Which of the following would be an inaccurate clinical manifestation of a retinal detachment? Pain Sudden onset of a greater number of floaters Cobwebs Bright flashing lights

Pain Explanation: Patient may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Patients do no complain of pain.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? Diverticulitis Hematemesis Paralytic ileus Ulcerative colitis

Paralytic ileus Explanation: Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply. A) Application of topical antibiotic ointment B) Maintenance of a supine position for the first 48 hours postoperative C) Fluid restriction to prevent orbital edema D) Administration of loop diuretics to prevent orbital edema E) Use of an ocular pressure dressing

Patients who undergo eye removal need to know that they will usually have a large ocular pressure dressing, which is typically removed after a week, and that an ophthalmic topical antibiotic ointment is applied in the socket three times daily. Fluid restriction, supine positioning, and diuretics are not indicated.

A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed? Gastric ulcer Pernicious anemia Hyperthyroidism Sickle cell anemia

Pernicious anemia Explanation: More than 50% of clients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.

A nurse is developing a teaching plan for a client with an immunodeficiency. What would the nurse need to emphasize? Select all that apply. Signs and symptoms of bleeding Prophylactic medication regimens Need to interrupt therapy for short periods Ways to manage stress Maintenance of a well-balanced diet

Prophylactic medication regimens Ways to manage stress Maintenance of a well-balanced diet Explanation: Teaching for clients with immunodeficiency disorders should focus on the signs and symptoms that indicate infection, prophylactic medication regimens, the need for continued therapy without interruptions, ways to manage stress, and measures to ensure optimal nutritional status.

While providing personal care for a client, the nurse observes that the client is not comfortable with the close physical proximity. How will the nurse alleviate the discomfort of the client during personal care? Speak words or phrases in the client's language. Maintain sufficient distance. Ensure that the client's family member is present. Provide simple explanations of the need for physical proximity.

Provide simple explanations of the need for physical proximity. Explanation: Simple explanations of the need for physical proximity during clinical procedures and personal care alleviate the discomfort that the client may experience. Maintaining sufficient distance and ensuring that the client's family member is present may not help alleviate the discomfort some clients may experience. Speaking words or phrases in the client's language will help in communicating with clients who do not speak English.

Which statement is accurate regarding refractive surgery? Refractive surgery will alter the normal aging of the eye. Refractive surgery may be performed on all clients, even if they have underlying health conditions. Refractive surgery may be performed on clients with an abnormal corneal structure as long as they have a stable refractive error. Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea.

Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. Explanation: Refractive surgery is an elective procedure and is considered a cosmetic procedure (to achieve clear vision without the aid of prosthetic devices). It is performed to reshape the cornea for the purpose of correcting all refractive errors. Refractive surgery will not alter the normal aging process of the eye. Clients with conditions that are likely to adversely affect corneal wound healing (corticosteroid use, immunosuppression, elevated intraocular pressure) are not good candidates for the procedure. The corneal structure must be normal and refractive error stable.

The nurse is completing a cultural heritage assessment. Which items will be included in this portion of the health assessment? Select all that apply. Religion Participation in religious traditions Health history Celebration of holidays Use of tobacco Use of alternative therapies

Religion Participation in religious traditions Celebration of holidays Use of alternative therapies Explanation: Health-related beliefs and practices (such as religious traditions and celebration of holidays, and use of alternative health practices) can reflect the cultural heritage of the client. Asking questions can assist in determining cultural heritage. Religion, tobacco use, and/or health history assists in the health history but does not reflect upon heritage or culture.

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal? Ultrasonography Retinal Imaging Retinal Angiography Retinoscopy

Retinal Angiography Explanation: The nurse is most correct to instruct the client that his skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.

A client with HIV will be started on a medication regimen of three medications. What drug will the nurse instruct the client about? Protease inhibitor Integrase inhibitors Reverse transcriptase inhibitors Hydroxyurea

Reverse transcriptase inhibitors Explanation: Reverse transcriptase inhibitors are drugs that interfere with the virus' ability to make a genetic blueprint. A protease inhibitor is a drug that inhibits the ability of virus particles to leave the host cell. The integrase inhibitors are a class of drug that prevents the incorporation of viral DNA into the host cell's DNA. Hydroxyurea is a drug that is used as an adjunct therapy that tries to halt the progression of AIDS.

Which diagnostic test distinguishes between conductive and sensorineural hearing loss? Whisper test Rinne test Audiometry Weber test

Rinne test Explanation: Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. In the whisper test, the client with normal acuity can correctly repeat what was whispered from 1 to 2 feet away. Audiometry is used to detect hearing loss. The Weber test uses bones conduction to test lateralization of sound.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? Bathing or hygiene self-care deficit Ineffective cerebral tissue perfusion Complicated grieving Risk for injury

Risk for injury Explanation: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? Roll the client in a blanket. Cover the client with a wet cloth. Place the client with the head positioned slightly below the rest of the body. Avoid immediate IV fluid therapy.

Roll the client in a blanket. Explanation: When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear? Scleral buckle Pars plana vitrectomy Pneumatic retinopexy Phacoemulsification

Scleral buckle Explanation: The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.

A client with AIDS develops pneumocystis pneumonia. The nurse would most likely expect to include administration of which agent in the client's plan of care? Aerosolized pentamidine Clindamycin Azithromycin TMP-SMZ

TMP-SMZ Explanation: TMP-SMZ is the treatment of choice for pneumocystis pneumonia. Alternative regimens may include dapsone and TMP, primaquine plus clindamycin, or atovaquaone suspension. Aerosolized pentamidine is not used because of its limited efficacy and more frequent cases of relapse. Azithromycin or clarithromycin are the preferred prophylactic agents for Mycobacterium avium complex.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage I Stage II Stage III Stage IV

Stage III Explanation: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do? Stand at a position diagonal to the client. Have the client use a finger to occlude the ear to be tested. Stand about 1 to 2 feet away from the ear to be tested. Speak a phrase in a low normal tone of voice.

Stand about 1 to 2 feet away from the ear to be tested. Explanation: When performing the whisper test, the nurse covers the untested ear wtih the palm of the hand and then whispers softly form a distance of 1 to 2 feet from the unoccluded ear and out of the client's sight. The client with normal hearing can correctly repeat what was whispered.

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis? Urine specimen for culture and sensitivity Blood specimen for electrolyte studies Stool specimen for ova and parasites Sputum specimen for acid fast bacillus

Stool specimen for ova and parasites Explanation: A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances.

Which of the following refers to a group that shares characteristics identifying the group as a distinct entity? Minority Culture Subculture Race

Subculture Explanation: Subculture refers to a particular group that shares characteristics identifying the group as a distinct entity. The term minority describes a group of people who differ from the majority in a society in terms of cultural characteristics. Culture provides a means for understanding people's values and beliefs. Race refers to biologic differences in physical features, such as skin color and eye shape.

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? Superficial Full-thickness Superficial partial-thickness Deep partial-thickness

Superficial Explanation: A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Obtaining consent for examination Supporting the client's emotional status

Supporting the client's emotional status Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

Which of the following is the treatment of choice for acoustic neuromas? Surgery Radiation Chemotherapy Palliation

Surgery Explanation: Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to radiation or chemotherapy. There would be no need for palliation.

A client comes to the walk-in clinic complaining of an earache. The cause is found to be impacted cerumen. The client asks the nurse what he can do at home to soften hardened cerumen. What should the nurse recommend to a client to soften hardened cerumen? Avoid harsh sunlight. Increase intake of red meat. Increase intake of beta-carotene. Take nonprescription preparations.

Take nonprescription preparations. Explanation: The nurse should recommend nonprescription preparations that are available for softening hardened cerumen. Increasing the intake of red meat or beta-carotene or avoiding harsh sunlight will not soften the cerumen.

A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply. Temperature 105 degrees F (40.6 degrees C) Lack of sweating Increased thirst Weakness Delirium Bradypnea

Temperature 105 degrees F (40.6 degrees C) Lack of sweating Delirium Explanation: A patient with heat stroke typically exhibits a temperature of 105 degrees F (40.6 degrees C) or higher; profound central nervous system dysfunction; hot, dry skin; anhidrosis (absence of sweating); tachypnea; hypotension; and tachycardia. Increased thirst and weakness would suggest heat exhaustion.

Prior to an eye exam for possible macular degeneration, the nurse completes a history of symptoms. The nurse is aware that a diagnostic sign of age-related dry macular degeneration is: The abrupt onset of symptoms. Reporting that a straight line appears crooked. The appearance of tiny, yellow spots in the field of vision. Reporting that letters in words appear broken.

The appearance of tiny, yellow spots in the field of vision. Explanation: Drusen are tiny yellow spots that patients who have dry AMD report.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The client is in hypovolemic shock. The client has experienced extensive full-thickness burns. The paramedic administered high doses of opioids during transport. The client has experienced partial-thickness burns.

The client has experienced extensive full-thickness burns. Explanation: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? The client is assumed to have a spinal cord injury until proven otherwise. The most lethal injuries are often the most readily apparent. Most multiple trauma victims exhibit evidence of the trauma. Injuries have occurred to at least three distinct organ systems.

The client is assumed to have a spinal cord injury until proven otherwise. Explanation: With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? The client's heart rate is rapid and regular. The client's urinary output is 0.3 to 0.5 mL/kg/hour. The client's breathing is unlabored, and skin is clammy. The client is alert and conscious.

The client's urinary output is 0.3 to 0.5 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.3 to 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? It helps determine the percentage of the total body surface area (TBSA) that is burned. The client's condition is likely to deteriorate after 72 hours. The wound is susceptible to infections. The early appearance of the burn injury may change.

The early appearance of the burn injury may change. Explanation: The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

The nurse is evaluating the client while taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision? The nurse would anticipate the client identifying numbers and shapes. The nurse would anticipate a cross-eyed appearance. The nurse would anticipate responding to the color names in the pictures. The nurse would anticipate no differentiation in between colors.

The nurse would anticipate the client identifying numbers and shapes. Explanation: The nurse is correct to anticipate the client being able to identify numbers and shapes dictated by different color codes. The other options do not test for color vision or indicate an inability to differentiate colors.

The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful? The nurse would stand directly in front of the client. The nurse would stand between the client and physician. The nurse would stand across the room but in direct alignment from the client. The nurse would stand laterally to the client, opposite side to where the physician is standing.

The nurse would stand laterally to the client, opposite side to where the physician is standing. Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The client stands with the feet together and arms extended. In the event that the client begins to sway (an abnormal result), the nurse is most helpful to stand on the lateral side of the client, opposite side to where the physician is standing to ensure that the client does not fall.

The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment? The power of the lens to accommodate will be decreased. Increased fat will be around the orbit. The skin around the eyes will be more elastic. The depth of the eyeball will be increased, leading to myopia.

The power of the lens to accommodate will be decreased. Explanation: In the older adult, the accommodative power of the lens decreases, resulting in the need to hold reading materials at increasing distances to focus. Orbital fat and skin elasticity decrease. The depth of the eyeball does not change with age.

Which data is bimportant for the nurse to record while assessing the client with an open wound? Time and place of the injury Degree of movement and range of motion Time when the client last received a tetanus immunization Vital signs

Time when the client last received a tetanus immunization Explanation: If the client has an open wound, the nurse ascertains when the client last received a tetanus immunization. This vital information helps assess the risk of infection in a client with an open wound. The assessment begins with measuring the client's vital signs. It is important to ascertain the time and place of injury with the degree of movement and range of motion in all cases, not just in the case of an open wound.

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Tissue tearing away from supporting structures Incision of the skin with well-defined edges, usually long rather than deep Skin tear with irregular edges and vein bridging Denuded skin

Tissue tearing away from supporting structures Explanation: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually long rather than deep

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply. To support ventilation in a client with basal skull trauma To provide airway support to a client with facial trauma To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions

To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions Explanation: Endotracheal intubation is indicated to establish an airway for a client who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the client to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions. In the case of potential facial trauma or basal skull fracture, the nasopharyngeal airway should not be used because it could enter the brain cavity instead of the pharynx.

A young client is being seen by a pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to the right cornea, and is now at risk of developing an infection. Which nursing intervention would be contraindicated for a client at risk for infection? To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid. Avoid using a container of ophthalmic medication for anyone other than the client. Change gauze eye bandages using aseptic technique. Wash hands before examining the eyes or performing any procedure about the face.

To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid. Explanation: Avoid contaminating the medication dropper or tube by holding the tip above the eye and adjacent tissue. Using a separate container of ophthalmic medication for each client prevents cross-contamination. Maintaining asepsis prevents the introduction and transmission of infection. Handwashing prevents infection.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? To prevent collapse and further injuries To keep fire and smoke from airway To extinguish flames more quickly To promote blood flow to the brain and vital organs

To keep fire and smoke from airway Explanation: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. Stop, drop, and roll method is a quick efficient means to distinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

A client has been diagnosed with HIV and has been placed on antiretroviral therapy. What does the nurse inform the client will be required for determining the progression of the disease as well as guiding drug therapy? The client will be required to stop the medication for 2 weeks and then have laboratory studies drawn to determine if the antiretroviral therapy has cured the disease. Viral load and T4-cell counts will be performed every 2 to 3 months. More antiretroviral medication will be added every 2 to 3 months. The Western blot test will be monitored every 6 months to see if the virus is still present.

Viral load and T4-cell counts will be performed every 2 to 3 months. Explanation: Viral load testing is used to guide drug therapy and follow the progression of the disease. Viral load tests and T4-cell counts may be performed every 2 to 3 months once it is determined that a person is HIV positive. The medication should be adhered to and not discontinued. There is no cure for the disease at this time. Antiretroviral therapy is not generally changed or added to without reason or lack of response. The Western blot is used for confirmation of the presence of the HIV virus.

Which term defines the balance between the amount of HIV in the body and the immune response? Viral set point Window period Primary infection stage Viral clearance rate

Viral set point Explanation: The viral set point is the amount of virus in the body after the initial immune response subsides is referred to as the viral set point, which results in an equilibrium between HIV levels and the immune response that may be elicited. During the primary infection period, the window period occurs because a person is infected with HIV but negative on the HIV antibody blood test. The period from infection with HIV to the development of antibodies to HIV is known as the primary infection stage. The amount of virus in circulation and the number of infected cells equals the rate of viral clearance.

A patient is scheduled to have an auditory brain stem response in 2 days. What does the nurse instruct the patient to do in preparation for the test? Shave several areas on the scalp where the electrodes will be placed. Do not eat or drink 8 hours prior to testing. Wash and rinse hair before test but do not apply any other hair products. Omit daily medications prior to testing.

Wash and rinse hair before test but do not apply any other hair products. Explanation: The auditory brain stem response is a detectable electrical potential from cranial nerve VIII and the ascending auditory pathways of the brain stem in response to sound stimulation. Electrodes are placed on the patient's scalp and on each earlobe. Patients are instructed to wash and rinse their hair prior to this study but to avoid applying any other hair product.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: p24 antigen test for confirmation of diagnosis. Western blot test for confirmation of diagnosis. polymerase chain reaction test for confirmation of diagnosis. T4-cell count for confirmation of diagnosis.

Western blot test for confirmation of diagnosis. Explanation: The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.

what is transcultural nursing?

a term sometimes used interchangeably with cross-cultural, intercultural, or multicultural nursing, refers to research-focused practice that focuses on patient-centered, culturally competent nursing

cholesteatoma

a tumor of the external layer of the eardrum into the middle ear, often resulting from chronic otitis media. they usually do not cause pain; however, if treatment or surgery is delayed, they may burst or destroy the mastoid bone. they are not normally the result of metastasis and are not self-limiting

A client is diagnosed with common variable immunodeficiency (CVID). What would the nurse identify as potential infections for this client? Select all that apply. Haemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus Pneumocystis jiroveci pneumonia

aemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus Explanation: Clients with CVID are susceptible to infections with Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Opportunistic infections with Pneumocystis jiroveci pneumonia are seen only in clients with a concomitant deficiency in T-lymphoycte immunity

vitreoretinal surgery

any operation to treat eye problems involving the retina, macula, and vitreous fluid. These include retinal detachment, macular hole, epiretinal membrane and complications related to diabetic retinopathy. not associated with high levels of pain

Kaposi sarcoma (KS) is diagnosed through skin scraping. biopsy. visual assessment. computed tomography.

biopsy. Explanation: KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote increased metabolic rate. increased glucose demands. increased skeletal muscle breakdown. decreased catabolism.

decreased catabolism. Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases. occur most commonly in the aged population. develop as a result of treatment with antineoplastic agents. disappear with age.

develop early in life after protection from maternal antibodies decreases. Explanation: These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins. Without treatment, infants and children with these disorders seldom survive to adulthood.

what are the most common causes of blindness and visual impairment among adults 40 years or older?

diabetic retinopathy macular degeneration glaucoma cataracts

what are the common causes of blindness and visual impairment among adults 40 yrs or older?

diabetic retinopathy, macular degenerations, glaucoma, cataracts *individuals with hyperopia, astigmatism, and myopia are not in risk category for blindness

what is the Amsler grid?

diagnostic tool that aids in the detection of visual disturbances caused by changes in the retina, particularly the macula, as well as the optic nerve and the visual pathway to the brain for MACULAR problems like macular degeneration

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? escharotomy debridement allograft silvadene application

escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared charred. What depth of burn injury does the client have? full thickness (third degree) superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) fourth degree

full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appears charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

A client is in the ED after being struck in the left eye with a baseball, leaving a large ecchymosis and edema. In client education, the nurse explains to the client the functions of the various structures of the eye. What are functions of the eyelids? Select all that apply. impact ocular light spread tears produce tears eliminate dust

impact ocular light spread tears Explanation: The eyelids adjust the amount of light that enters the eye and spread tears over the surface of the eye. The eyelids do not produce tears. The eyelids protect against foreign bodies but do not eliminate them.

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent: common adverse reactions to corticosteroid therapy. expected drug effects that should diminish over time. incorrect ointment application. increased intraocular pressure (IOP).

increased intraocular pressure (IOP). Explanation: Headache and blurred vision are symptoms of increased IOP, such as from glaucoma. Ophthalmic corticosteroids may trigger an episode of acute glaucoma in susceptible clients. Although the effects of some drugs may diminish with continued use, this doesn't happen with ophthalmic corticosteroids. Incorrect ointment application doesn't cause headache or blurred vision.

Which category of drugs is contraindicated in clients with glaucoma? mydriatics NSAIDs beta-blockers prostaglandins

mydriatics Explanation: Dilation of the pupil can further obstruct drainage of aqueous fluid, raise IOP, and damage whatever vision remains. Atropine is contraindicated in clients with glaucoma.