Concepts Unit 6 - Sensory

Early osteoporosis is treated with ___________

biophosphonates and exercise. Calcium and Vitamin D may also be advised. Rational This is standard treatment for osteoporosis.

A patient wearing corrective lenses has a visual acuity of 20/200. The nurse knows this patient has which characteristic? 1 - Legally blind 2 - Age-related presbyopia 3 - Low night vision due to loss of rods 4 - Proper correction for astigmatism

1 - Legally blind Rational Vision correctable to 20/200 is by definition legally blind. This patient is able to see at 20 feet what the healthy eye can see at 200 feet. Night vision is not related to visual acuity. The patient's age is unknown, as is the patient's astigmatism correction.

The nurse is performing an assessment on a patient with labyrinthitis. Which symptom(s) would likely to be noted? Select all 1 - Nausea 2 - Ear pain 3 - Nystagmus 4 - Loss of hearing 5 - Extra production of cerumen

1, 3 & 4 1 - Nausea 3 - Nystagmus 4 - Loss of hearing Rational Labyrinthitis refers to an inflammation of the vestibular portion of the labyrinth of the inner ear. Manifestations include sensorineural hearing loss, nystagmus, and nausea. There is no increase in production of cerumen or ear pain.

When communicating with a patient who is hearing impaired, the nurse should: Select all 1 - sit at eye level facing the patient 2 - use a slightly higher tone than usual 3 - enunciate clearly 4 - speak directly into the patient's ear 5 - use simple, short sentences

1, 3, & 5 1 - sit at eye level facing the patient 3 - enunciate clearly 5 - use simple, short sentences Rational (1) Sitting at eye level facing the patient, (3) enunciating clearly, and (5) speaking in short sentences makes it easier for the person to perceive what is being communicated. (2) Higher tones are not necessarily effective. (4) Speaking directly into the patient's ear is not effective.

What advice may you give an aging adult to help prevent macular degeneration? Select all 1 - Do not smoke, or quite if you do 2 - Maintain a healthy weight, especially do not carry weight around waist. 3 - Avoid bending or heavy lifting 4 - Drink with a straw

1 & 2 1 - Do not smoke, or quite if you do 2 - Maintain a healthy weight, especially do not carry weight around waist. Rational (1) Smoking doubles the risk for macular Degeneration and (2) excess weight—especially around the waist—puts a person at increased risk as well. (3) Drinking with or without a straw and (4) bending at the waist have no associated risk with macular degeneration.

The nurse is caring for a patient who has had his eye removed after suffering an injury. The patient is a candidate for the placement of an artificial eye. Which statement by the patient indicates understanding of when an artificial eye will be placed? 1 - "I should have my artificial eye placed in about 6 weeks." 2 - "I am excited that my new eye will be placed in about 2 weeks." 3 - "Unfortunately, I will not have my artificial eye until about 6 months." 4 - "It will likely take about a year before I can be fitted for my artificial eye."

1 - "I should have my artificial eye placed in about 6 weeks." Rational The traditional time between eye removal and the placement of a permanent prosthesis is approximately 6 weeks. Two weeks, about 6 months, or 1 year are not the appropriate time for an artificial eye placement.

The patient presents to the clinic after falling from her bike and is diagnosed with a Grade II ankle sprain. The nurse should make which statements to the patient regarding the treatment of her sprained ankle? Select all 1 - "Rest your ankle as much as possible." 2 - "Prop your ankle on pillows while resting." 3 - "You should wrap your ankle with an elastic bandage." 4 - "Take stimulant laxatives with your narcotic pain medication." 5 - "Place an ice pack on your ankle for 30 minutes every 4 hours." 6 - "Begin walking on your injured ankle after 24 hours, and increase your ambulation as tolerated."

1 - "Rest your ankle as much as possible." 2 - "Prop your ankle on pillows while resting." 3 - "You should wrap your ankle with an elastic bandage." Rational The nurse should educate the patient about the acronym RICE: rest, ice, compression, and elevation. The patient will not likely be prescribed a narcotic pain medication for a grade II sprain. In addition, increased fluids and dietary fluids would be recommended first, then a stool softener, and, lastly, a laxative. The patient should use an ice pack for 10 to 20 minutes every 1 to 2 hours. The patient should not walk on the ankle until cleared by the physician.

Before eye surgery, a patient is instructed to take stool softeners. When asked about the rationale for taking the stool softener, an appropriate response would be: 1 - "The medication reduces the possibility of straining at stool postoperatively." 2 - "The medication prevents constipation caused by anesthetic agents." 3- "The medication cleanses the gastrointestinal tract." 4 - "The medication enhances surgical recovery."

1 - "The medication reduces the possibility of straining at stool postoperatively." Rational (1) Stool softeners help decrease the possibility of straining to pass stool. Straining may cause increased intraocular pressure. Giving stool softeners is not used for (2) reducing possible constipation from operative drugs, (3) cleansing the gastrointestinal tract, or (4) enhancing recovery.

A nurse responds to a roadside emergency and finds a middle-age man with pain and tenderness over the left leg. The nurse notes a closed bone deformity with inability to move the leg. While waiting for the paramedics, what is the most important nursing action? 1 - Immobilization of the leg 2 - Realigning the bones 3 - Applying warm packs 4 - Elevating the extremity

1 - Immobilization of the leg Rational The most important action is to immobilize the leg so that bone fragments do not do more tissue damage and so movement doesn't cause increased pain. (2) The nurse must not try to realign the bones. (3) Warm packs are not applied to a fracture and the nurse wouldn't have them in this situation. (4) Elevating the extremity would be helpful if possible after the leg is immobilized.

The nurse should watch for signs of potential complications in a young adult patient with a fractured femur with internal fixation and long leg cast, such as Select all 1 - Infection or osteomyelitis 2 - Compartment syndrome 3 - Pneumonia or stroke 4 - Pulmonary fat embolus 5 - Electrolyte imbalance 6 - Nonunion of bone

1 - Infection or osteomyelitis 2 - Compartment syndrome 4 - Pulmonary fat embolus 6 - Nonunion of bone Rational A fat embolus is a threat when a long bone such as the femur is fractured; infection and possible osteomyelitis, compartment syndrome, and non-union of the bone are other potential complications for which to watch. (3) Pneumonia or stroke is not likely in a young adult. (5) Electrolyte imbalance is a possibility for any patient undergoing injury and surgery but would be more likely in an older adult.

The nurse is preparing to care for a patient who requires skeletal traction. The nurse knows which statement is true regarding skeletal traction? 1 - It has a high risk of infection. 2 - It is used for only fractures of the lower extremity bones. 3 - It uses a series of removable pins, ropes, and weights to realign bones. 4 - It requires nurses to frequently assess and modify the amount of weight applied

1 - It has a high risk of infection. Rational Because of the pins or wires inserted into the affected bone, risk of infection is high and pin care must be meticulously performed. Skeletal traction does not allow the nurse to modify the amount of weight applied. Skeletal traction is used for the management of musculoskeletal conditions not limited to fractures.

People with diabetes may face several eye problems and diseases as a complication of their illness. Which of the following can cause severe vision loss or blindness in a person with diabetes? Select all 1 - Glaucoma 2- Retinopathy 3 - Presbyopia 4 - Cataracts

1, 2 & 4 1 - Glaucoma 2- Retinopathy 4 - Cataracts Rational Diabetics may face a group of eye diseases, including (1) glaucoma, (4) cataracts, and (2) retinopathy. While diabetics may also experience (3) presbyopia, it is not associated with blindness and diabetics are not at increased risk.

After eye surgery, a patient is instructed to avoid movements that increase the venous pressure in the head, neck, and eyes. Which movement(s) increase(s) venous pressure? Select all 1 - Straining 2 - Bending over 3 - Keeping the head up 4 - Sudden head movements 5 - Strenuous exercises

1, 2 & 5 1 - Straining 2 - Bending over 5 - Strenuous exercises Rational (1) Straining with lifting heavy objects or to pass stool, (2) bending over with the head down, and (5) strenuous exercise can all increase intracranial pressure and venous pressure in the head and neck, which in turn increases intraocular pressure. (3) Keeping the head up and (4) sudden head movements do not increase intraocular pressure.

The patient presents to the clinic for a routine exam. Which signs or symptoms, if demonstrated or reported by the patient, indicate a possible eye disorder? Select all 1 - Double vision 2 - Blurred vision 3 - Flashing lights 4 - Tear production 5 - Irises of differing colors

1, 2, & 3 1 - Double vision 2 - Blurred vision 3 - Flashing lights Rational Eye disorders may manifest with flashing lights, blurred vision, and double vision. Different color irises are unusual but do not impair vision. Tear production is normal; excessive tearing is not.

A patient has been diagnosed with sensorineural hearing loss. The patient questions potential causes of this type of hearing loss. Which are associated with a sensorineural hearing loss? Select all 1 - Meningitis 2 - Use of ibuprofen (Motrin) 3 - Use of furosemide (Lasix) 4 - Wax buildup in the ear 5 - Exposure to loud noises

1, 2, 3, & 5 1 - Meningitis 2 - Use of ibuprofen (Motrin) 3 - Use of furosemide (Lasix) 5 - Exposure to loud noises Rational There are two types of hearing loss related to problems in the ear: (1) sensorineural and (2) conductive. The majority of hearing loss is due to a disorder of the hearing nerve (sensorineural loss). Conductive hearing loss is caused by a problem transmitting sound impulse through the auditory canal, the tympanic membrane, or the bones of the middle ear. Damage to the eardrum, use of ibuprofen or furosemide, and repeated exposure to loud noises may be associated with sensorineural hearing loss. Conductive hearing loss may be attributed to wax buildup in the ear.

Which nursing action(s) demonstrate(s) appropriate care of a patient who is visually impaired? Select all 1 - Introduce self before touching 2 - Speak slowly with a loud voice 3 - Keep the door ajar 4 - Ensure ready access to the call button for assistance 5 - Assist with feeding using the clock method

1, 4 & 5 1 - Introduce self before touching 4 - Ensure ready access to the call button for assistance 5 - Assist with feeding using the clock method Rational To avoid startling the person, you should (1) introduce yourself before touching him or her. (4) The call button should be positioned so the patient knows where it is and where it can be quickly reached. (5) Describing foods on the plate by where they would be positioned on a clock face helps the person eat independently. (2) Speaking slowly with a loud voice may be used to speak to a hearing impaired person. (3) Keeping the door ajar may add disruptive noises.

A patient returns 1 week after receiving hearing aids and states, "I guess I may as well return these-I just cannot get used to them." What is an appropriate nursing response? Select all 1 - "Maybe a different type of hearing aid would be better for you." 2 - "You have not been able to hear well for a long time. Adjusting to the way you hear the sound through a hearing aid may take quite a bit of time, but its will be worth it. " 3 - "In order to adjust to the hearing aids, you must wear them most of the time. Are you able to keep them in most of the time, or do you spend most of your time without them." 4 - "My daughter adjusted to hers in just a few days. Something is not right here."

2 & 3 2 - "You have not been able to hear well for a long time. Adjusting to the way you hear the sound through a hearing aid may take quite a bit of time, but its will be worth it. " 3 - "In order to adjust to the hearing aids, you must wear them most of the time. Are you able to keep them in most of the time, or do you spend most of your time without them." Rational (2) It can take several months to realize the full benefit of hearing aids. The more a patient goes without them, the longer it will take to adjust. (3) The patient should be encouraged to keep trying. (1) It is too early to test other aids. Test one for several months. (4) People adjust to hearing aids differently.

The nurse reads in the chart that a patient has been diagnosed with uveitis. The nurse knows that which structure(s) are involved in this diagnosis? Select all 1 - Retina 2 - Choroid 3 - Optic nerve 4 - Ciliary body 5 - Vitreous humor

2 & 4 2 - Choroid 4 - Ciliary body Rational Uveitis affects the uveal tract, which includes the iris, the ciliary body, and the choroid. The retina, the optic nerve, and the vitreous humor are not part of the uveal tract.

A male patient was informed that he would need to wear a pair of corrective lenses for astigmatism. When asked about the condition, the patient demonstrates understanding when he states that: 1 - "Astigmatism is hardening of the ciliary muscles." 2 - "Astigmatism is an irregular curvature of the cornea." 3 - "Astigmatism enables focusing of light in front of the retina." 4 - "Astigmatism is an increased opacity of the lens."

2 - "Astigmatism is an irregular curvature of the cornea." Rational (2) Astigmatism is caused by an irregular curvature of the cornea. (1) This is not astigmatism. (3) Astigmatism focuses light in several points. (4) Cataracts are increased opacity of the lens.

A nurse has just received shift report on hour assigned orthopedic patients. Which patient should the nurse check on first? 1 - A young trauma patient with a below-the-knee amputation who is having phantom pain 2 - An older adult woman with a total hip replacement who needs assistance with the bedpan 3 - A women when an external fixation device who has a fever and foul oder at pin sites 4 - A man with a full leg cast who reports persistent pain despite elevation and pain medication

2 - An older adult woman with a total hip replacement who needs assistance with the bedpan Rational Obtaining assistance for the hip replacement patient needing help with the bedpan should be handled first so that the patient does not have an accident with feces or urine in the bed that might contaminate her wound and dressing; a nursing assistant could be sent to attend to the patient. (1) The patient with phantom pain needs assistance but does not take priority. (3) The woman with an external fixation device who has a fever and foul odor at the pin site is experiencing an infection and the surgeon needs to be notified so that treatment can be started. This would be the nurse's second action. (4) The man with the full leg cast experiencing pain needs to be reassessed and pain relief sought.

A patient with a history of Meniere disease is discussing dietary options with the nurse. The patient demonstrates an understanding of the necessary dietary changes by agreeing to restrict which food item? 1 - Lean meats 2 - Canned soups 3 - Potassium-rich foods 4 - Complex carbohydrates

2 - Canned soups Rational A low-sodium diet and niacin (a water-soluble B vitamin) have been shown to be effective in reducing the symptoms of Meniere disease. Canned soups have elevated sodium levels and should be avoided. There is no reason to restrict lean meats, potassium-rich foods, or complex carbohydrates.

A nurse is assuming recovery room care of a 52-year-old patient who had carpal tunnel repair. On receiving the patient, what is the priority nursing assessment? 1 - Sensation in the fingertips 2 - Color, warmth, and capillary refill 3 - Condition of the dressing 4 - Range of motion

2 - Color, warmth, and capillary refill Rational Checking circulation in the hand by checking color, warmth and capillary refill is the priority nursing assessment after carpal tunnel surgery. (1) Sensation in the fingertips will be important after any local anesthetic has worn off. (3) The condition of the dressing is checked but is not the greatest priority. (4) Range of motion of the wrist is not checked at this time so soon after surgery.

The appearance of a petechial rash and respiratory distress 2 to 3 days after a fracture should be reported promptly because they may be symptomatic of which life-threatening complication? 1 - Infection 2 - Fat embolism 3 - Nerve damage 4 - Vitamin deficiency

2 - Fat embolism Rational Fat embolism is a rare but serious complication of a bone fracture that has an abundance of marrow fat. The fat globules released when fat-bearing bone marrow is fractured must be large enough or sufficient in number to occlude a blood vessel, either partially or completely. Rupture of small venules in the area permits entrance of fat globules into the circulation. Signs and symptoms of fat embolism include a change in mental status followed by respiratory distress, tachypnea, crackles and wheezes that are heard when auscultating the lungs, rapid pulse, fever, and petechiae.

The nurses recognize the importance of testing intraocular pressure in the diagnosis of which disorder? 1 - Myopia 2 - Glaucoma 3 - Hyperopia 4 - Strabismus

2 - Glaucoma Rational Glaucoma is a condition caused by elevations in intraocular pressure. Myopia, hyperopia, and strabismus are visual disorders but are not associated with elevated ocular pressures.

A patient is scheduled for a stapedectomy. The LPN/LVN should understand that this procedure is done when a patient has which problem? 1 - Mastoiditis 2 - Otosclerosis 3 - Labyrinthitis 4 - Meniere disease

2 - Otosclerosis Rational Otosclerosis refers to the excess formation of bone in the ears. This impairs hearing. A potential treatment is a stapedectomy. Stapedectomy is not used for mastoiditis, labyrinthitis, or Meniere disease.

A young man is admitted to the emergency department after an injury to the left leg sustained playing football. He is complaining of pain around the knee and upper tibia. Which data from the nurse's assessment would indicate a fracture of the tibia rather than a connective tissue injury of the knee? 1 - Pain and soft tissue swelling around the knee and an abrasion on the knee 2 - Pain, ecchymosis below the knee, and crepitation with any movement of the area 3 - Pain, swelling, and loss of function of the foot 4 - Limping, when walking, facial grimace, and some swelling of the knee and lower leg

2 - Pain, ecchymosis below the knee, and crepitation with any movement of the area Rational Signs of fracture include pain, swelling, ecchymosis into the tissues surrounding the fracture and crepitation upon movement of the affected bone. (1) An abrasion of the knee, pain, and soft-tissue swelling most likely indicate a connective tissue injury. (3) Loss of function of the foot would not occur with a fracture of the upper tibia. (4) The patient would be unable to walk with a fracture of the upper tibia due to extreme pain when trying to walk.

A young patient returns from the operating room after a below-the-knee amputations and is alert and quiet. The stump is elevated with the dressing dry and intact. What is the priority problem for this patient? 1 - Altered body image 2 - Potential for bleeding 3 - Altered mobility 4 - Insufficient knowledge

2 - Potential for bleeding Rational After an amputation, a risk for bleeding is a priority safety concern. (1) Disturbed body image will occur but is not the priority at this time. (3) Impaired mobility has occurred but is not the priority nursing diagnosis at this time. (4) Deficient knowledge is a probability regarding stump care, adjusting to a prosthesis, and using crutches or a wheelchair as well as maintaining balance while up but is not the priority at this time.

A patient with glaucoma is being treated with miotic eyedrops. Following administration of the medication, the nurse should note which reaction? 1 - Pupil dilation 2 - Pupil constriction 3 - Decreased edema of the cornea 4- Diminished redness of the sclera

2 - Pupil constriction Rational Miotics, such as pilocarpine, are administered for treatment of glaucoma to cause pupillary constriction and lower intraocular pressure. Miotics do not result in pupil dilation, changes in sclera coloring, or changes to the cornea.

The patient presents to the clinic with a compound fracture of the right leg. The nurse anticipates the administration of which classes of medications? Select all 1 - Aspirin 2 - Tetanus booster 3 - Hepatitis B vaccine 4 - Intravenous (IV) morphine 5 - IV antibiotics

2 - Tetanus booster 4 - Intravenous (IV) morphine 5 - IV antibiotics

The nurse is reviewing a patient's chart and notes the patient's vision in his left eye is 20/70. The nurse uses this information to make which interpretation of the patient's vision? 1 - The patient can read the line on the chart labeled 20 at 70 feet. 2 - The patient can read the line on the chart labeled 70 at 20 feet. 3 - The patient can see 20/70ths of what a patient of that age can see. 4 - The patient can see 20/70ths of what a normally sighted person can see.

2 - The patient can read the line on the chart labeled 70 at 20 feet. Rational The Snellen eye chart is used to assess visual acuity. The chart is placed 20 feet from the patient, and first one eye is occluded and then the other eye is occluded. The person begins reading lines of letters that decrease in size. Visual acuity is expressed as a fraction for each eye. The numerator (first) figure indicates the distance between the patient and the chart. The denominator (second) figure expresses the distance at which a person with 20/20 vision could read that line. Visual acuity of 20/20 in each eye is normal. A visual acuity of 20/70 means the smallest line this patient could read at 20 feet can be read at 70 feet by a person with 20/20 (or normal) vision. Visual acuity of 20/200 indicates the person is legally blind.

A difference in the postoperative care of the patient with a knee replacement compared with a patient after a hip replacement is that the patients with a hip replacement. 1 - Has less chance of developing a deep venous thrombosis 2 - Remains on bed rest for several days 3 - Is allowed to stand at the bedside 4 -Has a CPM machine to exercise the joint

3 - Is allowed to stand at the bedside Rational The patient with a hip replacement is gotten up to stand at the side of the bed on the 1st postoperative day. (1) Both patients have a risk of developing a deep venous thrombosis. (2) The patient with a hip replacement is not on bed rest. (4) Only the patient with a knee replacement has a continuous passive motion machine to exercise the joint.

A nurse evaluates the visual acuity of a patient using the Snellen chart. Which statement is true regarding the use of the Snellen chart. 1 - The chart is placed 40 feet away from the patient 2 - The patient reads the letters using one eye at a time 3 - The numerator (top number) indicted the smallest line that the patient could read 4 - The denominator (bottom number) refers to the patient's distance form the chart.

2 - The patient reads the letters using one eye at a time Rational (2) Visual acuity is tested by having the patient read the lines on the Snellen chart with one eye while the other eye is completely covered. Then the opposite eye is tested in the same manner. (1) The patient is normally 20 feet away from the chart. (3) The top number indicates how far away the patient is. (4) The bottom number refers to the distance that people with normal vision can read the line of the chart.

The nurse is caring for a patient with a hearing disorder who has begun to complain of dizziness and a disorder of the vestibular system is suspected. Which diagnostic test would be most appropriate? 1 - Rinne test 2 - Vestibular testing 3 - Audiometric testing 4 - Evoked-response audiometry

2 - Vestibular testing Rational An electronystagmography test assesses for diseases of the vestibular system. Evoked-response audiometry assesses the abnormality of nerve pathways between the brainstem and the eighth cranial nerve. Audiometry is used to assess the presence and degree of hearing loss. Impedance audiometry evaluates middle-ear function.

Which instruction must be included in the discharge teaching of a patient who has undergone corneal transplant? 1 - Increasing physical activity 2 - Wear an eye shield when in close contact with children or pets 3 - Remove pressure dressing as needed 4 - Lie only on the operative side

2 - Wear an eye shield when in close contact with children or pets Rational (2) The patient should protect the eye with an eye shield when around children or pets to prevent an accidental injury to the eye with disruption of the corneal transplant. (1) Physical activity should be reduced. (3) The pressure dressing should be kept in place. (4) Lie on the opposite side of the surgery.

While ambulating, a patient with Meniere disease complains of dizziness and vertigo. An immediate nursing action would be to: 1 - provide oxygen 2 - assist the patient to supine position 3 - administer nausea medication 4 - notify the provider

2 - assist the patient to supine position Rational (2) Although answer 3 might also be relevant, safety concerns decree that having the patient lie down to prevent a fall or injury from bumping into things takes priority. The patient might only be dizzy, not nauseated. (1) Meniere disease is not from oxygen deprivation. (3) This may be necessary but will not help immediately. (4) The provider does not need to be reminded of normal protocol.

When administering eardrops to an adult, the nurse would: 1 - draw the pinna upward and toward the front of the head 2 - draw the pinna upward and toward the back of the head 3 - pull the pinna downward and toward the front of the head 4 - pull the pinna downward and toward the back of the head

2 - draw the pinna upward and toward the back of the head Rational (2) Pulling the pinna up and backward straightens the ear canal on the adult, allowing the drops to coat the whole canal and reach the eardrum. (1) Pulling the pinna toward the front of the head will block the ear canal. (3) This will not straighten the ear canal. (4) This will not straighten the ear canal.

Older adults are more prone to conductive hearing loss and tinnitus because of 1 - hypertrophy of the cerumen glands 2 - hardened cerumen 3 - widening of the auditory canal 4- hair loss in the auditory canal

2 - hardened cerumen Rational (2) With age, cerumen becomes less moist and may harden, making it difficult to be expelled on its own. The hardened cerumen may cause a conductive hearing loss if not removed. In aging, there is not (1) hypertrophy of the cerumen glands or (3) widening of the auditory canal. (4) Aging may cause hair changes in the auditory canal, but not resulting in conductive hearing loss.

The nurse emphasizes safety precaution to be 60-year-old female Hispanic patient with Meniere disease. An appropriate nursing approach would be to: 1 - use the patient's first name when addressing her 2 - include family members in instructions 3 - address decision making to the patient 4 - set a specific schedule for providing instructions

2 - include family members in instructions Rational (2) Including family members when giving safety instructions will help reinforce needed interventions and help keep the patient safe from falls. (1) Using the patient's name will not increase safety. (3) Addressing decision making to the patient is in conflict with 2. (4) There is no need to schedule instructions for a specific time.

A nurse is assisting an older adult at home who has rheumatoid arthritis in the hands and wrists. The nurse would intervene to teach the patient about joint protection if the patient 1 - turned the doorknob counterclockwise 2 - used the palms of the hands to push up and off the bed 3 - carried groceries into the house using both hands 4 - pushed the door open with the arm

2 - used the palms of the hands to push up and off the bed Rational A patient with rheumatoid arthritis in the hands and wrists should not use the palms of the hands to push up off the bed as this puts undue pressure on the wrists. (1) Turning the doorknob either direction should be done slowly and gently to prevent pain in the fingers and wrists. (3) Groceries should be carried using both arms and hands and by holding the package close to the chest. (4) Pushing the door open with an arm rather than the wrist and hand is appropriate.

A patient has a caloric test to check for alterations in vestibular function. The patient asks the nurse what the normal test findings will be. The LPN/LVN should explain to the patient that if the test is normal, the patient is likely to experience which symptom? 1 - No response 2 - Flushing of the skin 3 - Nausea and vomiting 4 - Tingling of the earlobes

3 - Nausea and vomiting Rational The caloric test will be used to assess vestibular functioning. A normal result may cause the patient to experience nystagmus, vertigo, nausea, and vomiting. No response indicates an abnormal result. The patient is not expected to experience flushing of the skin or tingling of the earlobes.

After sustaining a rotator cuff tear, a patient's arm is placed in a sling. The patient is instructed to rest and to take ibuprofen (Motrin) for pain. Which patient statement indicates a need for further teaching? 1 - "I will have less stomach upset if I take the pills with food." 2 - "I will not be able to play tennis for a while." 3 - "I need to rest in bed for the next 2 days." 4 - "The sling must be worn most of the time."

3 - "I need to rest in bed for the next 2 days." Rational The patient with a rotator cuff tear does not need bed rest. (1) Taking ibuprofen with food is advisable to prevent stomach irritation. (2) The patient will not be able to play tennis for a while. (4) The sling should be worn most of the time.

The patient in the outpatient surgery center has just returned from surgery to decompress the medial nerve as treatment for carpal tunnel syndrome. Which assessment finding immediately after surgery would alert the nurse to a possible complication? 1 - Nail beds that are pink 2 - Numbness of the fingertips 3 - 5-second nail bed capillary refill 4 - Fingertips that are warm to the touch

3 - 5-second nail bed capillary refill Rational The nurse should assess the perfusion of the hand. A capillary refill time of more than 3 seconds may indicate a problem and should be reported to the surgeon immediately. Right after surgery, the patient is not expected to have sensation in the fingers. Pink, warm skin is a normal finding.

Which finding, if present after a patient has right eye surgery, should be reported to the provider immediately as it may indicate hemorrhage? 1 - Experiencing some confusion 2 - Tearing of the unaffected eye 3 - A sudden pain in the affected eye 4 - Difficulty reading with the unaffected eye

3 - A sudden pain in the affected eye Rational A complication of eye surgery is hemorrhage. Sudden onset of pain in the affected eye may signal bleeding and should be reported to the surgeon. Some confusion may be normal following general anesthesia. Tearing of the unaffected eye and difficulty reading with the unaffected eye are not signs of hemorrhage.

A patient with a plaster cast of the right arm complains of itching underneath the cast. What should the nurse do to alleviate the symptom? 1 - Encourage deep breaths and scratch the other arm 2 - Insert a cotton-tip applicator under the cast 3 - Forcefully inject 50 mL of air underneath the cast 4 - Administer pain medications

3 - Forcefully inject 50 mL of air underneath the cast Rational Forcefully injecting 50 mL of air underneath the case helps relieve itching. (1) For some people scratching the other arm will help relieve itching and this could be suggested if the air injection isn't helpful. (2) Nothing should ever be inserted under the cast to help relieve itching. (4) Pain medication does not usually relieve itching.

A nurse applies a vibrating tuning fork to the middle of a patient's forehead. What response would indicate normal hearing? 1 - Hearing the sound in the back of the head 2 - Feeling a vibration but hearing no sound 3 - Hearing the sound in the middle of the head 4 - Feeling a vibration and hearing a sound i the temporal area

3 - Hearing the sound in the middle of the head Rational (3) This is Weber test, and hearing the sound in the middle of the head is normal. (1) Hearing the sound in the back of the head is abnormal. (2) Hearing no sound is abnormal. (4) Hearing a sound in the temporal area is abnormal.

An older adult is admitted for cataract extraction. Which sign or symptom is associated with this condition? 1 - Increased tearing 2 - Increased farsightedness 3 - Increasing complaints about glare 4 - Bluish discolorations

3 - Increasing complaints about glare Rational (3) Increasing complaints about glare are associated with the growth of a cataract. Retinopathy is frequent in patients with diabetes, either from overgrowth of blood vessels or from hypertension that causes increased pressure and rupture of vessels. (1) Cataracts do not cause tearing. (2) They do not alter the point of focus on the retina. (4) Cataracts are not blue.

The nurse is caring for a patient who has had a knee replacement. Within 2 to 3 days, the LPN/LVN can likely anticipate which change in the plan of care? 1 - Walker training 2 - Enemas until clear 3 - Quadriceps setting exercises 4 - Cessation of pain medication

3 - Quadriceps setting exercises Rational Within 2 to 5 days, quadriceps-strengthening exercises, and straight-leg raising are started. Quadriceps setting exercises are accomplished by lying supine, straightening the legs, and pushing the back of the knees into the bed. Exercises are taught by the physical therapist, and the nurse often assists the patient in performing them. The arthroplasty patient then progresses to ambulation with a walker or crutches. There is no need to administer enemas to the patient. Pain medication may be needed for several days after the surgery.

A patient has been scheduled for LASIK surgery to correct his myopia. Which statement best describes this procedure? 1 - Diagonal incisions are made in the cornea; the central cornea is not incised. 2 - The cornea is reshaped using pulsation of ultraviolet (UV) light on the central superficial tissue. 3 - Superficial layers of the cornea are lifted while a laser reshapes the deeper layers of tissue. 4- Vertical incisions are made in the central cornea followed by reshaping of the lens with pulsation of UV light.

3 - Superficial layers of the cornea are lifted while a laser reshapes the deeper layers of tissue. Rational LASIK uses a laser to correct myopia. The middle layer of the cornea is reshaped with a laser after a very thin outer layer of the cornea is peeled back. The outer layer is replaced. Incisions and UV light are not used in the LASIK procedure.

When assigned to care for a patient who has gout, the LPN/LVN should assess for which condition? 1 - Evidence of unilateral joint deformity 2 - Decreased range-of-motion of most joints 3 - Swelling and pain in the big toe or other joint 4 - Signs of compression of the spine from collapsed vertebrae

3 - Swelling and pain in the big toe or other joint Rational Gouty arthritis most commonly impacts the big toe but may be noted in other joints. There are no signs of spinal nerve compression associated with the condition. Joint deformity and reduction in the range-of-motion of most of the body's joints are not associated with the condition.

A patient complains of tinnitus. Which factor, if present in the patient's history, may be most closely related to the patient's complaint? 1 - The patient takes zinc supplement. 2 - The patient is a high school student. 3 - The patient takes large doses of aspirin. 4- The patient is slightly dehydrated from gastroenteritis.

3 - The patient takes large doses of aspirin Rational Ototoxicity is often initially manifested with tinnitus. Excessive doses of aspirin are linked to ototoxicity. Zinc supplements, being a high school student, and dehydration are not directly associated with tinnitus.

A patient has a corneal abrasion. Which factor in the patient's history is most closely related to this problem? 1 - The patient smokes. 2 - The patient is 75 years old. 3 - The patient wears contact lenses. 4 - The patient has a history of renal disease.

3 - The patient wears contact lenses. Rational A corneal abrasion may result from exposure to contact lenses. This is especially true when the lenses are worn extensively. Smoking, age, and renal disease are not associated with corneal abrasions.

LPNs/LVNs can do much to decrease the incidence of osteoporosis by teaching all female patients that preventive measures include sufficient calcium intake and which other intervention? 1 - Sufficient fluid intake 2 - Supplemental B vitamins 3 - Weight-bearing exercises 4 - Total avoidance of alcohol

3 - Weight-bearing exercises Rational Health promotion activities geared to reduce the risk of osteoporosis include weight-bearing exercise. Weight-bearing exercise increases bone health. The supplementation of vitamin B intake will not prevent osteoporosis. Fluid intake is positive for overall health. Drinking in moderation is not associated with the onset of osteoporosis.

A 24-year-old woman limps into the emergency department after twisting her ankle during a soccer game. On examination, there is local swelling and difficulty maintaining balance. What immediate therapeutic measure(s) should the nurse provide? Select all 1 - Application of elastic bandage 2 - Application of an ice pack 3 - Elevation of the ankle 4 - Ankle rest and limited weight bearing 5 - Application of a topical anesthetic

3, 2, 1 1 - Application of elastic bandage 2 - Application of an ice pack 3 - Elevation of the ankle Rational Elevation, application of ice, and then wrapping with an elastic bandage are immediate measures used in the emergency department for a sprained ankle. (4) Ankle rest and limited weight bearing should occur after leaving the E. R. (5) A topical anesthetic is not used for an ankle sprain.

While looking at a card with a geometric grid of identical squares, a patient is asked to focus on a central dot and to describe any distortions of the surrounding boxes. Which patient statement indicates a need for further diagnostic testing? 1 - "I get dizzy staring at these boxes for so long." 2- "I am beginning to see color differences in the squares." 3 - "I can see all the boxes surrounding the dot." 4 - "There are wavy lines around the central dot."

4 - "There are wavy lines around the central dot." Rational (4) Seeing wavy lines on an Amsler grid is an indication that the patient has a macular problem. Further evaluation by an ophthalmologist should be sought quickly. (1) Getting dizzy does to indicate macular degeneration. (2) Color difference is not a function of macular degeneration. (3) Seeing all of the boxes indicates normal vision.

During the immediate postoperative period following cataract removal, what is the priority action by the LPN/LVN? 1 - Position the patient on the operative side. 2 - Keep the patient on bed rest for the first 24 hours. 3 - Provide cold compresses to be placed on the operative side. 4 - Be sure the patient avoids coughing, sneezing, rubbing the eyelids, or sudden movements of the head.

4 - Be sure the patient avoids coughing, sneezing, rubbing the eyelids, or sudden movements of the head. Rational Immediately after cataract removal it is important to avoid coughing, sneezing, and rubbing the eyes or moving the head suddenly. The patient is not required to remain on bed rest. The patient should be positioned on the nonoperative side. Cold compresses are not used in the postoperative period.

When a patient is receiving Lasix for a problem with edema, which assessment relative to this drug is important to the patient's health? 1 - Measuring the blood pressure 2 - Determining whether the patient is nauseated 3 - Inquiring about constipation 4 - Checking for hearing loss

4 - Checking for hearing loss Rational (4) Lasix (furosemide) can cause tinnitus and hearing loss. (1) Measuring blood pressure may be important but does not indicate edema. (2) Lasix is not associated with nausea. (3) Diarrhea is associated with Lasix.

A woman complains of eye itching, tearing, halos around lights, and decreased central vision. Which symptoms most clearly relates to macular degeneration? 1 - Eye itching 2 - Tearing 3 - Halos around light 4 - Decreased central vision

4 - Decreased central vision Rational (4) A decrease in central vision is most characteristic of macular degeneration. (1) Eye itching, (2) tearing, and (3) halos around lights are not symptoms of macular degeneration.

When a patient experiences dizziness and vertigo, which action should be included in the patient's care? 1 - Reminding the patient to limit intake of salt 2 - Telling the patient to increase intake of vitamin B12 3 - Encouraging the patient to remain as active as possible 4 - Instructing the patient to lie down and remain as still as possible

4 - Instructing the patient to lie down and remain as still as possible Rational The priority goal when caring for the patient experiencing vertigo and dizziness is patient safety. The patient should be encouraged to rest during the episode. Limiting salt is helpful if the patient has been diagnosed with Meniere disease but is not helpful during an acute episode. Vitamin B12 has not been shown to be helpful with Meniere disease.

The LPN/LVN is caring for a patient who has had a total hip replacement. Which intervention should be implemented for this patient to help prevent dislocation? 1 - Adjust the patient's chair so that the hips are flexed in a normal position. 2 - Ensure the surgical bone cement remains firmly bonded with the prosthesis. 3 - Assist the patient to bear weight on the operative side within the first 24 hours. 4 - Secure the abduction wedge between the legs until the surgeon requests removal.

4 - Secure the abduction wedge between the legs until the surgeon requests removal. Rational Use of an abduction wedge in the postoperative period is needed to prevent abduction. The pillow is applied immediately after surgery in the recovery area. It is to remain in place until removal is requested by the surgeon. Weight bearing is not necessarily indicated in the first 24-hour postoperative period. Normal sitting postures are to be avoided; they could potentially result in dislocation.

The nurse is reviewing the assessment documentation on an older adult patient made the previous shift. The nurse notes what changes occur in the eye with aging? 1 - Equal in size, not completely round, and not reactive to light. 2 - Completely round, pupils bulging, and pupil size enlarges. 3 - Reactive to light, wider visual field, and ability to see dim light. 4 - Sunken look, cornea flattens, and cataracts may form.

4 - Sunken look, cornea flattens, and cataracts may form. Rational Changes that occur in the eye with aging include the eyes appear to be sunken because subcutaneous fat and tissue elasticity decreases; the cornea flattens and develops an irregular curvature after age 65. The lens of the eye changes age 40, gradually losing water and becoming hard and cataracts may form. Pupils are still reactive to light, pupils flatten rather than bulging, and a narrower visual field occurs and pupil size becomes smaller, rather than larger, causing an inability to see dim light

A nurse in an urgent care center is reviewing the medical record of a client who is undergoing evaluation for angle-closure glaucoma. Which of the following findings is an indication of this disorder? A - Insidious onset of painless loss of vision B - Gradual reduction in peripheral vision C - Severe pain around the eyes D - Intraocular pressure 12 mm Hg

C - Severe pain around the eyes Rational A - Acute-angle glaucoma is painful and has a sudden onset B - Gradual loss of peripheral vision is a manifestation of primary open-angle glaucoma C - Severe pain around eyes that radiates over the face is a manifestation of acute angle-closure glaucoma D - An IOP of 12 mm Hg is within the expected reference range. Elevated IOP is an manifestation of angle-closure glaucoma.

The patient presents to the emergency department after a soccer game. The patient reports that she made a sharp turn and heard and felt a large pop from her knee. The patient reports, "Now, when I'm walking, it feels like my knee just gives out, and I almost fall. Plus, it's twice the size of my other knee, and I can't straighten it all the way." The nurse recognizes that these symptoms correspond with which injury? 1 - Torn meniscus 2 - Dislocated patella 3 - Torn quadriceps muscle 4 - Torn anterior cruciate ligament injury

4 - Torn anterior cruciate ligament injury Rational The turning motion followed by a loud pop with the patient's complaint of severe swelling, joint instability, and decreased extension indicates a torn anterior cruciate ligament. A meniscal tear has less swelling and joint instability, although some exists. If the patient had dislocated her patella, the patella would be in a different spot than normal, and this would be part of the patient's chief complaint. The patient's complaint centers on the knee, not the quadriceps.

During a provider visit, a 65-year-old man complains of pain in his right eye associated with excessive tearing. The nurse notes that the eye is red and lashes rubbing against the cornea. A likely condition would be: 1 - ptosis 2 - exgtropion 3 - hordeolum 4 - entropion

4 - entropion Rational (4) When the eyelid is inverted and the lashes rub on the eyeball, it is called entropion. (1) Ptosis is a drooping of the lower eyelid. (2) Ectropion is when the eyelid folds outward. (3) Hordeolum is a disorder of the eyelid.

A nurse is reinforcing discharge teaching with a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A - "I should restrict rapid movements and avoid bending from the waist for several weeks." B - "I should wait until the day after surgery to wash my hair." C - "I will remove the dressing behind my ear in 7 days." D - "My hearing should be back to normal right after my surgery."

A - "I should restrict rapid movements and avoid bending from the waist for several weeks." Rational A - The client should avoid rapid movements and bending for the waist for 3 weeks following ear surgery B - The client should avoid showering and washing hair for at least several days up to 1 week following ear surgery. The ear must remain dry during this time. C - Middle ear surgery is preformed through the tympanic membrane, and the client will have a dry dressing within the ear canal. There is no external excision D - Decreased hearing is expected following middle ear surgery due to presence of a dressing within the ear canal and possible drainage.

A nurse is caring for a client who asks what her Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A - "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B - "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 20 feet." C - "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." D - "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

A - "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." Rational A - The first number is the distance (in feet) the client stand from the chart. The second number is the distance at which a visually unimpaired eye can see the same line clearly. B - Each eye has its own visual acuity, which includes both numbers C - The numerator of visual acuity results in a constant. It does not change with a client's ability to see clearly D - Each eye has its own visual acuity, which includes both numbers

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? Select all A - Enlarged adenoids B - Report of recent colds C - Client prescription for daily furosemide D - Light reflex visible on otoscopic exam in the affected ear E - Ear pain relieved by meclizine

A - Enlarged adenoids B - Report of recent colds E - Ear pain relieved by meclizine Rational A - Enlarged tonsils and adenoids are a finding associated with a middle ear infection B - Frequent colds are findings associated with a middle ear infection C - Furosemide is an ototoxic medication and can cause sensorineural hearing loss, but taking furosemide dose not cause a middle ear disorder D - Light reflexes are absent or in altered positions in a client who has a middle ear disorder E - Meclizine is prescribed to relieve vertigo for inner ear disorders but does not relieve the pain of a middle ear infection

A nurse is reinforcing teaching with a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A - Increase intake of deep yellow and orange vegetables B - Administer eye drops twice daily C - Avoid bending at the waist D - Wear an eye patch at night

A - Increase intake of deep yellow and orange vegetables Rational A - The nurse should instruct the client to increase dietary intake of carotenoids and antioxidants to slow the progression of the macular degeneration B - A client who has primary open-angle glaucoma should administer eye drops once or twice daily C - A client who is at risk for increased intraocular pressure, such as following cataract surgery, should avoid bending at the waist D - A client who has had eye surgery, such as cataract surgery, should wear an eye patch at night to protect the eye from injury

A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all A - Palpating the thyroid in the lower half of the neck B - Visualizing the thyroid on inspection of the neck C - Hearing a bruit when auscultating the thyroid D - Feeling the thyroid ascend as the client swallows E - Finding symmetric extension off the trachea on both sides of the midline

A - Palpating the thyroid in the lower half of the neck D - Feeling the thyroid ascend as the client swallows E - Finding symmetric extension off the trachea on both sides of the midline Rational A - The thyroid gland lies in the anterior portion of the lower half of the neck, just in front of the trachea B - An average-size thyroid gland is not visible on inspection C - A bruit indicates increased blood flow, possible due to hyperthyroidism. D - When the client swallows a sip of water, the nurse should feel the thyroid move upward with the trachea E - The thyroid glands lies in front of the trachea and extends symmetrically to both sides of the midline

A nurse in a provider's office if documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? Select all A - Posture B - Skin lesions C - Speech D - Allergies E - Immunization status

A - Posture B - Skin lesions C - Speech Rational A - Posture is part of the body structure or general appearance portion of the general survey B - Skin lesions are part of the body structure or general appearance portion of the general survey C - Speech is part of the behavior portion of the general survey D - Allergies are part of the health history not the general survey. E - Immunization status is part of the health history, not the general survey.

A nurse in a client is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? Select all A - Reduce expose to bright light B - Move head slowly when changing positions C - Do not eat fruit high in potassium D - Plan evenly spaced daily fluid intake E - Avoid fluids containing caffeine

A - Reduce expose to bright light B - Move head slowly when changing positions D - Plan evenly spaced daily fluid intake E - Avoid fluids containing caffeine Rational A - Remaining in a darken, quite environment can reduce vertigo, particularly when ti is severe B - Moving slowly when standing or changing positions can reduce vertigo C - The client who has vertigo should avoid foods containing high levels of sodium to reduce fluid retention, which can cause vertigo D - The client should plan to evenly space fluid intake throughout the day to prevent excess fluid accumulation in the semicircular canals. E - The client should avoid fluids containing caffeine or alcohol to minimize vertigo

A nurse in a provider's office is reinforcing teaching with the parent of a toddler about how to administer ear drops. Which of the following instructions should the nurse include? Select all A - "Place your son on his unaffected side when you are ready to put in the drops." B - "Warm the medication by gently rolling it between your hands for a few minutes." C - "Gently shake the medication if it is in suspension form." D - "Keep your son on his side for 5 minutes after you put in the drops." E - "Tightly pack your song's ear with cotton after you put in the drops

A, B, C & D A - "Place your son on his unaffected side when you are ready to put in the drops." B - "Warm the medication by gently rolling it between your hands for a few minutes." C - "Gently shake the medication if it is in suspension form." D - "Keep your son on his side for 5 minutes after you put in the drops." Rational A - The parents should have the child on his unaffected side to allow access to the affected ear to promote drainage of the medication by gravity into the ear B - The parents should warm the medication by rolling it between his hands. Administering the medication cold can cause dizziness C - The parents should gently shake medication that is in suspension form to disperse the medication evenly D - The parents should keep the child on his side to promote drainage of the medication by gravity into the ear. E - The parents should loosely pack the child's ear with cotton.

A nurse is reviewing information with a client who has osteoarthritis of the hip and knee. Which of the following instructions should the nurse reinforce? Select all A - Apply heat to joints to alleviate pain B - Ice inflamed joints following activity C - Install an elevated toilet seat D - Take tub baths E - Complete high-energy activities in the morning

A, B, C & E A - Apply heat to joints to alleviate pain B - Ice inflamed joints following activity C - Install an elevated toilet seat E - Complete high-energy activities in the morning Rational A - Applying heat to joints can provided temporary relief of pain B - Apply ice to inflamed joints following activity can decrease edema. C - An elevated toilet seat can decrease strain and pain of the affected joints D - Taking a tub bath places the client at risk for increased strain and pain on the affected joints when getting in and out of the tub and increase the risk for falls E - Encourage high-energy activity in the morning is recommended as part of a daily routine to promote independence

A nurse is reinforcing discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include? Select all A - Remove throw rugs in walkways B - Use prescribed assistive devices C - Remove clutter from the environment D - Walk with caution on icy surfaces E - Maintain lighting of doorway areas

A, B, C & E A - Remove throw rugs in walkways B - Use prescribed assistive devices C - Remove clutter from the environment E - Maintain lighting of doorway areas Rational A - Removing throw rugs in walkways can help to prevent a fall and bone fracture B - Assistive devices can help to prevent a fall and bone fracture C - Removing clutter from the environment can help prevent tripping, falling, and a bone fracture D - The client should avoid walking on icy surfaces during inclement weather to help prevent a fall and bone fracture.

A nurse is caring for a 2-year-old child who has had three ear infections in the past 5 months. Which of the following complications is the child at risk for developing long-term? A - Balance difficulties B - Rash C - Speech delays D - Mastoiditis

C - Speech delays Rational A - Balance difficulties can be present with otitis media. However, it is not a long-term complication B - Rash is not a compilation of otitis media. However, the nurse should monitor a client prescribed antibiotic therapy for acute otitis media for a rash, which can indicate antibiotic sensitivity. C - Speech delay is a potential complication of otitis media D - Mastoiditis can be a result of otitis media. However, it is not a long-term complication

A nurse is assisting with health screenings at a health fair. The nurse should identify that which of the following clients are at risk for osteoporosis? Select all A - 40-year-old client who takes prednisone for asthma B - 30-year-old client who jogs 3 miles a daily C - 45-year-old client who takes phenytoin for seizures D - 65-year-old client who has a sedentary lifestyle E - 70-year-old client who has smoked for 50 years.

A, C, D & E A - 40-year-old client who takes prednisone for asthma C - 45-year-old client who takes phenytoin for seizures D - 65-year-old client who has a sedentary lifestyle E - 70-year-old client who has smoked for 50 years. Rational A - Prednisone affects the absorption and metabolism of calcium and places the client at risk for osteoporosis B- Weight-bearing activities decrease the risk for osteoporosis due to placing stress on bones, which promotes bone rebuilding and maintenance C - Phenytoin affects the absorption and metabolism of calcium and places the client at risk for osteoporosis D - A sedentary lifestyle places the client at risk for osteoporosis because bones need the stress of weight bearing activity for bone rebuilding and maintenance

A nurse is collecting data from a client who has osteoarthritis of the knee and fingers. Which of the following manifestations should the nurse expect to find? Select all A - Heberden's nodes B - Swelling of all joints C - Small body frame D - Enlarged joint size E - Limp when walking

A, D, & E A - Heberden's nodes D - Enlarged joint size E - Limp when walking Rational A - Heberden's nodes are enlarged nodules on the distal interphalangeal joints of the hands and feet of a client who has osteoarthritis. B - Swelling and pain of all joints is a manifestation of rheumatoid arthritis. A local inflammation of a joint is related to osteoarthritis C - A small body frame is a risk factor for rheumatoid arthritis. Obesity is a risk factor for osteoarthritis D - A client can manifest enlarged joints due to bone hypertrophy E - A client can manifest a limp when walking due to pain from inflammation in the localized joint.

A nurse is caring for a toddler who has had rhinitis, cough, and diarrhea for 2 days. The toddlers's tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse make? A - "Your child has an ear infection that requires antibiotics." B - "You child could experience transient hearing loss." C - "You child will need to be on a decongestant until this clears." D - "You child will need to have a myringotomy

B - "You child could experience transient hearing loss." Rational A - Rhinitis, cough, diarrhea, and orange discoloration of the tympanic membrane are findings of otitis media with effusion (OME). The child does not require antibiotics at this time B - Rhinitis, cough, diarrhea and an orange discoloration of the tympanic membrane are findings of OME. Transient hearing loss is a complication of OME. C - Rhinitis, cough, diarrhea, and an orange discoloration of the tympanic membrane are finds of OME. Decongestants are not recommended for the treatment of OME.

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? Select all A - Reddened gums B - Lowered vocal pitch C - Tooth loss D - Glare intolerance E - Thickened eardrums

C - Tooth loss D - Glare intolerance E - Thickened eardrums Rational A - The nurse should expect an older adult's gums to be pale B - The nurse should expect an older adults' vocal pitch to rise C - Tooth loss and gum disease are common in older adults D - Older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. E - Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals.

A nurse in an outpatient facility is caring for an infant who has manifestations of acute otitis media (AOM). The nurse should identify which of the following as risk factors for otitis media? Select all A - Breastfeeding without formula supplementations B - Attending daycares 4 days/week C - Immunizations up to date D - History of a cleft palate repair E - Parents who smoke cigarettes outside

B - Attending daycares 4 days/week D - History of a cleft palate repair E - Parents who smoke cigarettes outside Rational A - Breastfeeding helps to protect against AOM because breast milk contains secretory immunoglobulin A B - Infants who attend daycare have an increased rick of OM due to the increased potential of exposure to infants and children who have viral/bacterial respiratory infections C - The pneumococcal conjugate vaccine decreased the incidence of OM D - Infants born with cleft palate are more prone to AOM because micro-organisms can easily enter the eustachian tubes E - Exposure to secondhand some increased an infant's risk of AOM

a nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A - Olfaction B - Auscultation C - Palpation D - Percussion

B - Auscultation Rational A - Olfaction is the use of the sense of smell to detect any unexpected findings that the nurse cannot detect via other means, such as a fruity breath odor. Unless there is an open lesion of the client's abdomen, this is not the next step in an abdominal examination B - Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those two techniques. C - Palpation is the next step in examining other areas of the body, but not the abdomen D - Percussion is important for detecting gas, fluid, and solid masses in the abdomen, but it is not the next step in an abdominal assessment

A nurse is collecting data on a male older adult client who has a new diagnosis of glaucoma. Which of the following findings should the nurse recognize as risk factors associated with this disease? Select all A - Gender B - Genetic predisposition C - Eye trauma D - Age E - Diabetes mellitus

B - Genetic predisposition C - Eye trauma D - Age E - Diabetes mellitus Rational A - Gender is not a risk factor associated with glaucoma

A nurse is reviewing information about capsaicin cream with a client who reports continuous knee pain fro osteoarthritis. Which of the following information should the nurse reinforce? A - Continuous pain relief is provided. B - Inspect for skin irritation and cuts prior to application C - Cover the area with tight bandages after application D - Apply the medication every 2 hr during the day

B - Inspect for skin irritation and cuts prior to application Rational A - Capsaicin cream provided temporary relief of pain rather than continuous relief when applies several times daily B - Inspect the skin for irritation and cuts before applying capsaicin cream, because hot peppers in the cream can cause a painful burning sensation in areas of skin breakdown C - After capsaicin cream is applied, avoid covering the area with a tight bandage, which can cause increased skin irritation D - For maximum pain relief benefit, apply capsaicin cream up to four times a day

A nurse is assisting in the admission of an older adult client who has suspected osteoporosis. Which of the following findings should the nurse expect? Select all A - History of consuming one glass of wine daily B - Loss in heigh of 5.1 cm C - Body mass index (BMI) 21 D - Kyphotic curve at upper thoracic spine E - History of lactose intolerance

B - Loss in heigh of 5.1 cm C - Body mass index (BMI) 21 D - Kyphotic curve at upper thoracic spine E - History of lactose intolerance Rational A - A client who consumes more than three glasses of alcohol each day is at risk for developing osteoporosis because alcohol can increase bone loss. B - The loss of 2 inches of height is suggestive of osteoporosis due to fractures of the vertebral column C - The client who has a BMI of 21 is at risk of developing osteoporosis due to low body eight and thing body build, suggesting decreased bone mass D - Kyphosis curve is highly suggestive of osteoporosis due to fractures of the vertebrae causing the curve. E - Lactose intolerance is highly suggestive of osteoporosis due to possible lack of calcium intake

A nurse is showing a client who has a new prescription for timolol how to insert eye drops. The nurse should instruct the client to press on which of the following areas to prevent systemic absorption of the medication? A - Bony orbit B - Nasolacrimal duct C - Conjunctival sac D - Outer canthus

B - Nasolocrimal duct Rational A - Pressing on the bony orbit will not prevent systemic absorption of the medication B - Pressing on the nasolocrimal ducts blocks the lacrimal punctum and prevents systemic absorption of the medication C - Pressing on the conjunctival sac will not prevent systemic absorption of the medication D - Pressing on the outer canthus will not prevent systemic absorption of the medication

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A - Cataracts B - Open-angle glaucoma C - Macular degeneration D - Angle-closure glaucome

B - Open-angle glaucoma Rational A - A client who has cataracts experiences a decrease in peripheral and central vision due to opacity of the lens B - A gradual loss of peripheral vision is a manifestation associated with open angle glaucoma C - A client who has muscular degeneration experiences a loss of central vision D - A client who has angle-closure glaucoma experiences sudden nausea, severe pain, and halos around light

A nurse is assisting in the care of a client immediately following vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? A - Apply heat to the puncture site B - Place the client in a supine position C - Tuen the client every 1 hr D - Ambulate the client within the first hour postprocedure.

B - Place the client in a supine position Rational A - The client should have cold therapy applied to the puncture site to decrease bleeding and swelling following the procedure B - The client should remain in a supine position with bed flat for the first 1 to 2 hr following the procedure to allow for hardening of the cement C - The client should remain in a supine position with bed flat for 1 to 2 hr following the procedure D - The client should remain in a supine position with bed flat for 1 to 2 hr following the procedure

A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? Select all A - Collect the data in one continuous session B - Plan to allow plenty of time fro position changes C - Make sure the client has any essential sensory aids in place D - Tell the client to take her time answering questions E - Invite the client to use the bathroom before beginning the examination

B - Plan to allow plenty of time fro position changes C - Make sure the client has any essential sensory aids in place D - Tell the client to take her time answering questions E - Invite the client to use the bathroom before beginning the examination Rational A - The nurse should perform the various parts of the assessment in several shorter segments to avoid overtiring the client B - Because many older adults have mobility challenges, the nurse should plan to allow extra time for position changes. C- The nurse should make sure clients who use sensory aids have them available for use. The client has to be able to hear the nurse and see well enough to avoid injury D - Some older clients need more time to collect their thoughts answer questions, but most are reliable historians. Feeling rushed can hinder communication E - This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who have a smaller bladder capacity

A nurse is collecting data from an infant. The nurse should identify which of the following findings as manifestations of acute otitis media? Select all A - Decreased pain in the supine position B - Rolling head side to side C - Loss of appetite D - Increased sensitivity to sound E - Crying

B - Rolling head side to side C - Loss of appetite E - Crying Rational A - Infants who have acute otitis media have an increase in pain in the supine position from the fluid and pressure in the ear B - Infants who have acute otitis media roll their head side to side because of the pain and pressure in the ear C - Infants who have acute otitis media exhibit a loss of appetite due to the pain and pressure in the ear D - Infants who have acute otitis media have a decreased sensitivity to sound from the fluid and pressure in the ear E - Infants who have acute media exhibit crying and irritability from the pain

A nurse is reinforcing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? A - White bread B - White beans C - White meat of chicken D - White rice

B - White beans Rational A - White bread is not a calcium-rich food, but it is good source of carbohydrates B - White beans are a good source of calcium C - White meat of chicken is not a calcium-rich food, but it is a good source of protein D - White rice is not a calcium-rich food, but it is a good source of carbohydrates.

A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client Select all A - Address the client with the appropriate title and her last name B - Use a mix of open- and closed-ended questions C - Reduce environmental noise D - Have the client complete a printed history form E - Perform the general survey before the examination

B, C & E B - Use a mix of open- and closed-ended questions C - Reduce environmental noise E - Perform the general survey before the examination Rational A - The nurse should ask the client what she wants the nurse to call her B - Open-ended questions help the client tell her story in her own way. Closed-ended questions are useful for clarifying and verifying information the nurse gathers from the client's story C - A quite, comfortable environment eliminates distractions and helps the client focus on the important aspects fo the interview D - Having the client fill out a printed history form might deter the establishment of a therapeutic relationship. When the nurse asks about her history, the client might feel they are wasting time because she already wrote that information on the form E - The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process, such as the examination

A nurse is assessing and adult client's internal ear canals with an otoscope as part of the head and neck examination. Which of the following actions should the nurse take? Select all A - Pull the auricle down and back B - Insert the speculum slightly down and forward C - Insert the speculum 2 to 2.5 cm D - Make sure the speculum does not touch the ear canal E - Use the light to visualize the tympanic membrane in a cone shape

B, D & E B - Insert the speculum slightly down and forward D - Make sure the speculum does not touch the ear canal E - Use the light to visualize the tympanic membrane in a cone shape Rational A - The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years B - Inserting the speculum slightly down and forward follows the natural shape of the ear canal C - The nurse should insert the speculum 1 to 1.5 cm D - The lining of the ear canal is sensitive. Touching it with the speculum could cause pain E - Due to the angel of the ear canal, the nurse can only visualize the light reflecting off the tympanic membrane as a cone shape rather than a circle.

A nurse is reinforcing teaching with a client who has a new prescription for brimonidine ophthalmic drops and wears soft contact lenses. Which of the following instructions should the nurse include? A - "This medication can stain your contact lenses." B - "This medication can make your pupils constrict." C - "This medication can absorb into your contact lenses." D - "This medication can slow your heart rate."

C - "This medication can absorb into your contact lenses." Rational A - Rifampin can stain soft contact lenses. Brimonidine does not stain contact lenses B - Brimonidine can cause mydriasis or dilated pupils C - Brimonidine can absorb into soft contact lenses. The client should remove contact lenses, then instill the medication and wait at least 15 min before putting contact lenses back in D - Beta adrenergic blockers, such as timolol, can slow the heart rate. Brimonidine can cause hypertension or hypotension

A nurse is collecting data on a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? Select all A - Eye pain B - Floating spots C - Blurred vision D - White pupils E - Bilateral red reflexes

C - Blurred vision D - White pupils Rational A - Eye pain is manifestation associated with primary angle-closure glaucoma B - Floating spots are a manifestation associated with retinal detachment C - Blurred vision is a manifestation associated with cataracts D - White pupils are a manifestation associated with cataracts E - Bilateral red reflexes are absent in a client who has cataracts

A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial never V? Select all A - "Close your eyes." B - "Tell me what you can taste." C- "Clench your teeth." D - "Raise your eyebrows." E - "Tell me when you feel a touch."

C- "Clench your teeth." E - "Tell me when you feel a touch." Rational A - The first step of testing cranial nerve I, the olfactory nerve, is to have the client close his eyes. B - Testing cranial nerve VII, the facial nerve, involves testing the mouth for taste sensations C - Testing cranial nerve V, the trigeminal nerve, involves testing the strength of muscle contraction by asking the client to clench his teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint D - Testing cranial nerve VII, the facial nerve, involves testing for a range of facial expressions by having the client smile, raise his eyebrows, puff out his cheeks, and perform other facial movements E - Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when he feels a gentle touch of his face from a wisp of cotton

A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A - Palmar surface B - Fingertips C- Sorsal surface D - Base of the fingers

C- Sorsal surface Rational A - The palmar surface of the hands is especially sensitive to vibration, not temperature B - The fingertips are sensitive to pulsation, position, texture, size, and consistency, not temperature C - The dorsal surface of the hand is the most sensitive to temperature D - The base of the fingers is especially sensitive to vibration, not temperature.

A nurse is reinforcing postoperative teaching with a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A- "You can resume playing golf in 2 days." B - "You need to tilt your head back when washing your hair." C - "You can get water in your eyes in 1 day." D - "You need to limit your housekeeping activities."

D - "You need to limit your housekeeping activities." Rational A - The nurse should not instruct the client to resume playing golf for several weeks. This could cause a rise in intraocular pressure (IOP) or possible injury to the eye B - The nurse should not instruct the client to tilt his head back when washing his hair. This could cause a rise in IOP or possible injury to the eye C - The client should not get water in his eye for 3 to 7 days following cataract surgery to reduce the risk for infection and promote healing D - The nurse should instruct the client to limit housekeeping activities following cataract surgery. This activity could cause a rise in IOP or injury to the eye

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A - Provide emotional support to the family B - Instruct the family on care of the child C - Encourage the child to socialize with other toddlers D - Administer analgesics

D - Administer analgesics Rational A - Providing emotional support to the family is important because it promotes psychological esteem. However, another action is the priority B - Instructing the family on the care of the child is important to promote recovery from illness and security of the child's health. However, another action is the priority C - Encouraging the child to socialize with other toddlers is important to meet the child's need for love and belonging. However, another action is the priority. D - The priority action when using Maslow's hierarchy of needs is to meet the toddler's physiological need first. Administering analgesic to alleviate or decrease physical pain is the priority action for the nurse to take

A nurse is preforming an otoscopic examination of a client. Which of the following is an unexpected finding? A - Pearly, gray tympanic membrane (TM) B - Malleus visible behind the TM C - Presence of soft cerumen in the external canal D - Fluid bubble seen behind the TM

D - Fluid bubble seen behind the TM Rational A - A pearly, grey TM is an expected finding B - Visualization of the malleus behind the TM is an expected finding C - Cerumen of various colors, depending of the client's skin color or ethnic background, is an expected finding D - Fluid behind the TM indicated the possibility of otitis media and is not an expected finding

A nurse is reinforcing teaching with a client about preventing otitis externa. Which of the following instructions should the nurse include? A - Clean ears with a cotton-tipped swab daily B - Place earplugs in the ears right before sleeping at night C - Use a cool water irrigation solution to remove earwax D - Tip head to each side to remove water from the ears after showering

D - Tip head to each side to remove water from the ears after showering Rational A - The client should not insert anything in the ear because this can push cerumen into the eardrum, damage the epithelium, or puncture the eardrum. B - The client should wear earplugs only when swimming to reduce the risk of otitis externa C - The client should not use a cool irrigation solution to remove cerumen. Cool fluid can cause vertigo, dizziness, and nausea D - The client should remove water for the ear after showering to reduce the risk for otitis externa

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? A - Purulent lesion in the external ear canal B - Feeling of pressure in the ear C - Bulging red bilateral tympanic membranes D - Unilateral hearing loss

D - Unilateral hearing loss Rational A - Meniere's disease is an inner ear disorder. A purulent lesion in the external ear canal is not an expected finding B - A feeling of pressure in the ear can occur with otitis media, but it is not an expected finding in Meniere's C - Meniere's disease is an inner ear disorder. Bulging red bilateral tympanic membranes is a finding associated with a middle ear infection D - Unilateral sensorineural hearing loss is an expected finding in Meniere's disease