Exam #2

An excess of fluid being pushed into the intravascular space results in A. sore joints. B. edema. C. flushing. D. itching.

A & B

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side. B. Loosen the clothing around the client's waist. C. Check the client's motor strength. D. Document the time the seizure began.

A.

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A. Level of consciousness, motor function, pupillary response, and vital signs B. Deep tendon reflexes, vital signs, and coordinated movements C. Mental status, deep tendon reflexes, sensory function, and pupillary response D. CNs, motor function, and sensory function

A.

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? A. "I should sleep on my left side." B. "I should sleep on my right side." C. "I should sleep with my head flat." D. "I should not wear my glasses at any time."

A. After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Limit client physical activity. B. Provide client supervision. C. Leave the television on continuously. D. Speak loudly to the client.

B. Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? "Yes, you are free to move around as you wish." "Please ring for assistance when you wish to get out of bed." "We will have to get a prescription from your provider." "No, you are on strict bedrest and must not be up.

B. Can move around with assistance due to the vertigo.

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? A. Relief of depression B. Decreased tremors C. Delay in disease progression D. Improved bladder function

B. Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? A. Head elevated lying on the operative side B. On the nonoperative side with the legs abducted C. Side-lying with the affected leg internally rotated D. Side-lying with the affected leg externally rotated

B. Positioning after a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the primary health care provider's (PHCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or lying on the operative side (unless specifically prescribed by the PHCP) is avoided to prevent displacement of the prosthesis.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Aphasia B. Inability to recognize his family members C. Right hemiparesis D. Difficulty reading

B. The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? A. Presence of pigmented crescents in the macular area. B. Optic disc margins that are blurred around the edges. C. Optic disc that is a yellow-orange color. D. Presence of the macula located on the nasal side of the retina.

C. The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. Presence of pigmented crescents in the macular area is an abnormal finding. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. The optic dish margins are normally distinct and sharply demarcated, not blurred around the edges. The macula is located on the temporal side of the fundus of the eye, not on the nasal side of the retina. The correct answer of a normal finding is that the optic disc is a yellow-orange color.

Which assessment is most important for the nurse to monitor in a patient receiving an opioid analgesic? A. HR B. Mental status C. BP D. RR

D. Respiration's should be assessed for respiratory failure.

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What should the nurse tell the AP about older clients with hearing loss?

They are often distracted. They have middle ear changes. They respond to low-pitched tones. They develop moist cerumen production. Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate characteristics related to aging.

A nurse is completeing discharged instrutions with a client with a client following an acute onset of gout

limit alcohol consumption