Final Exam
A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? a. Absolute bed rest in a quiet, nonstimulating environment b. Supine positioning c. Passive range-of-motion exercises to prevent contractures d. Early initiation of physical therapy
a. Absolute bed rest in a quiet, nonstimulating environment The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.
A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home? a. Avoid bending the head below the waist. b. Lie on the stomach while sleeping. c. Maintain bed rest for 1 week. d. Lift weights to increase muscle strength.
a. Avoid bending the head below the waist. The nurse should encourage the patient to avoid bending or stooping for an extended period. Keep activity light. Avoid lying on the side of the affected eye the night after surgery. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
Bell palsy is a disorder of which cranial nerve? a. Facial (VII) b. Trigeminal (V) c. Vestibulocochlear (VIII) d. Vagus (X)
a. Facial (VII) Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia is a disorder of the trigeminal nerve and causes facial pain. Meniere syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barre syndrome is a disorder of the vagus nerve.
A colleague has been splashed in the eye with cleaning solution. Which of the following would be the priority? a. Irrigating the eye immediately with tap water b. Instilling a local anesthetic into the eye c. Finding out what the substance was d. Covering the eye with a clean sterile dressing
a. Irrigating the eye immediately with tap water With any ocular burn, the priority is to irrigate the eye with tap water immediately. While or after this is done, information about the substance can be obtained. A local anesthetic is instilled, particulate matter is removed, and irrigation continues until the pH normalizes. Then antibiotics are instilled and the eye is patched.
The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? a. Monitoring neurologic status closely b. Providing health education c. Maintaining the client's functional independence d. Promoting mobility
a. Monitoring neurologic status closely Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.
A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation? a. Report the suspicion to the local agency on aging within 24 hours of the visit. b. Try to convince the client to report the problem. c. Do nothing because the nurse has no proof of wrongdoing. d. Monitor the situation during subsequent visits.
a. Report the suspicion to the local agency on aging within 24 hours of the visit. The nurse must report the suspicion to the local agency on aging within 24 hours of the visit. Doing nothing and monitoring the situation during subsequent visits go against the nurse's legal and professional obligation, which is to report suspected abuse when it occurs. The client's disease process prevents him from reporting the problem.
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate? a. Signs and symptoms of conjunctivitis b. Signs and symptoms of ptosis c. Signs and symptoms of nystagmus d. Signs and symptoms of proptosis
a. Signs and symptoms of conjunctivitis Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes. Ptosis is drooping of the upper eyelid. Proptosis is an extended and upper eyelid that delays in closing or remains partially open. Nystagmus is an uncontrolled oscillating movement of the eyeball.
A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client? a. Sit or stand in front of the client when speaking. b. Use exaggerated lip and mouth movements when talking. c. Say the client's name loudly before starting to talk. d. Stand in front of a light or window when speaking.
a. Sit or stand in front of the client when speaking. Standing directly in front of a hearing-impaired client allows him or her to lip-read and see facial expressions that offer clues to what is being said. Using exaggerated lip and mouth movements can make lip-reading more difficult by distorting words. Backlighting can create glare, making it difficult for the client to lip-read. To get the attention of a hearing-impaired client, gently touch the client's shoulder or stand in front of the client.
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: a. Stay with the client and encourage him to eat b. Help the client fill out his menu c. Fill out the menu for the client d. Give the client privacy during meals
a. Stay with the client and encourage him to eat Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.
A client who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The client asks the nurse what these numbers specifically mean. What is a correct response by the nurse? a. "A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away." b. "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." c. "A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away." d. "A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away."
b. "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." The Snellen chart is a tool used to measure visual acuity. It is composed of a series of progressively smaller rows of letters and is used to test distance vision. The fraction 20/20 is considered the standard of normal vision. Most people can see the letters on the line designated as 20/20 from a distance of 20 feet. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.
The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? a. "I'm planning to avoid exposure to direct sunlight on my next vacation." b. "I'm certainly going to keep a close eye on my blood pressure from now on." c. "I've never exercised regularly, but I'm going to start working out at the gym daily." d. "I'm planning to talk with my pharmacist to review my current medications."
b. "I'm certainly going to keep a close eye on my blood pressure from now on." Hypertension is a major cause of vision loss, exceeding the significance of inactivity, sunlight, and adverse effects of medications.
The nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-administer these medications safely and effectively? a. Assess the client's functional status. b. Ask the client to demonstrate the instillation of her medications. c. Assess the client for any previous inability to self-manage medications. d. Determine whether the client can accurately describe the appropriate method of administering her medications.
b. Ask the client to demonstrate the instillation of her medications. The client or the caregiver at home should be asked to demonstrate actual eye drop administration. This method of assessment is more accurate than asking the client to describe the process or determining earlier inabilities to self-administer medications. The client's functional status will not necessarily determine the ability to administer medication safely.
The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? a. Potassium-sparing diuretics b. Cholinergics c. Loop diuretics d. Antibiotics
b. Cholinergics 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 health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? a. As long as the client receives the ordered medication, special care measures aren't necessary. b. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. c. The nursing staff should rely on the family to assist with care because family members know the client best. d. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed.
b. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. The charge nurse should inform the new nurse that clients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment takes top priority. Families are an important part of the client care team; however, they shouldn't be relied upon to deliver care. Family members may take turns sitting with the hospitalized client to help maintain client safety. All procedures should be explained in simple terms that the client can understand. Medications should be administered as ordered; however, they don't typically improve symptoms. Instead, they slow disease progression.
A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client? a. Apply direct pressure to the affected eye. b. Generously flush the affected eye with normal saline or water. c. Apply a patch to the affected eye. d. Generously flush the affected eye with a dilute antibiotic solution.
b. Generously flush the affected eye with normal saline or water. Chemical burns of the eye should be immediately irrigated with water or normal saline to flush the chemical from the eye. Antibiotic solutions, lubricant drops, and other prescription drops may be prescribed at a later time. Application of direct pressure may extend the damage to the eye tissue and should be avoided. Patching will be incorporated into the treatment plan at a later time to assist with the process of re-epithelialization, but at this point in the care of the client, patching will prevent irrigation of the eye.
A 6-year-old is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? a. The importance of compliance with antibiotic therapy b. Handwashing can prevent the spread of the disease to others. c. Signs and symptoms of complications, such as meningitis and septicemia d. The likely need for surgery to prevent scarring of the conjunctiva
b. Handwashing can prevent the spread of the disease to others. The nurse must inform the parents and child that viral conjunctivitis is highly contagious and instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths, and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy. Clients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not associated with viral conjunctivitis.
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? a. Before meals, to stimulate her appetite b. In the morning, with frequent rest periods c. All at one time, to provide a longer rest period d. Before bedtime, to promote rest
b. In the morning, with frequent rest periods Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the client may be too exhausted to eat. Procedures should be avoided near bedtime if possible.
Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? a. Swab the conjunctiva of unaffected residents for culture and sensitivity testing. b. Isolate affected residents from residents who have not developed conjunctivitis. c. Instill normal saline into the eyes of affected residents two to three times daily. d. Arrange for the administration of prophylactic antibiotics to unaffected residents.
b. Isolate affected residents from residents who have not developed conjunctivitis. To prevent spread during outbreaks of conjunctivitis caused by adenovirus, health care facilities must set aside specified areas for treating patients diagnosed with or suspected of having conjunctivitis caused by adenovirus. Antibiotics and saline flushes are ineffective and normally no need to perform testing of individuals lacking symptoms.
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? a. Relocation stress syndrome related to hospitalization b. Risk for caregiver role strain related to increased client care needs c. Defensive coping related to diagnosis of Alzheimer's disease d. Decisional conflict related to lack of relevant treatment information
b. Risk for caregiver role strain related to increased client care needs The client's spouse is at risk for caregiver role strain because the client has started to exhibit care needs beyond the spouse's capacity to provide. A diagnosis of Relocation stress syndrome may be appropriate for a client with inadequate preparation for hospital admission, transfer, or discharge; however, this client is confused and may be unable to grasp the meaning of such preparation. The spouse, on the other hand, is more likely to be relieved, at least physically, and able to rest because of the client's admission. Defensive coping and Decisional conflict aren't pertinent nursing diagnoses in this situation because the client's spouse is aware of and has accepted the client's disease.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? a. Increase the intake of calcium and proteins. b. Take small meals of soft consistency c. Include additional servings of fruits and raw vegetables d. Include fish, liver, and chicken in diet
b. Take small meals of soft consistency To help a client with trigeminal neuralgia, who suffers pain in the jaws meet his or her nutritional needs, the nurse should offer small meals of soft consistency. Foods may be pureed to minimize jaw movements when eating. There is no need for the client to increase the intake of fruits and raw vegetables, calcium, or proteins during trigeminal neuralgia. The nurse should avoid offering meat and fish in the diet because they require excessive chewing by the client.
A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the client? a. The client should do further research on the herbal remedy b. The client should discuss this new remedy with her ophthalmologist promptly. c. The client should monitor her IOP closely for the next several weeks. d. The client should report any adverse effects to her pharmacist.
b. The client should discuss this new remedy with her ophthalmologist promptly. Clients should discuss any new treatments with an ophthalmologist; this should precede the client's own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not possible.
A 56-year-old client has come to the clinic for his routine eye examination and is told he needs bifocals. The client 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 eye gets shorter, back to front, as we age and it changes how we see things." c. "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." d. "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 eye's ability for accommodation." 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 client's concerns.
A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what? a. Any appearance of redness of the eye b. Slight morning discharge from the eye c. A new floater in vision d. A "scratchy" feeling in the eye
c. A new floater in vision Cataract surgery increases the risk of retinal detachment and the client 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.
Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response? a. Administer donepezil every day b. Inform the family that this is a result of aging c. Assess the grandmother for adventitious lung sounds d. Recommends placement of the grandmother in a nursing home
c. Assess the grandmother for adventitious lung sounds Sudden onset of confusion may be the first symptom of an infection, such as pneumonia or urinary tract infection. The nurse needs to fully assess the situation before acting (such as telling the family this is a result of aging). Donepezil is used for Alzheimer's disease, which does not have acute onset. A recommendation for placement in a nursing home is premature without a full assessment at this time.
Which is a correct rationale for encouraging a client with otitis externa to eat soft foods? a. Chewy foods, such as red meat, may react with prescribed analgesics and antibiotics. b. Chewing may cause excessive drainage. c. Chewing may cause discomfort. d. Chewing may lead to further complications, such as otitis media.
c. Chewing may cause discomfort. The nurse encourages a client with otitis externa to eat soft foods or consume nourishing liquids because chewing may cause discomfort. Chewing will not react with the prescribed medications or cause complications such as otitis media and excessive drainage.
A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache? a. Distracting the client with activity b. Administering hydromorphone IV as needed c. Dimming the lights and reducing stimulation d. Initiating a patient-controlled analgesia (PCA) or morphine sulfate
c. Dimming the lights and reducing stimulation Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patient's pain.
The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? a. Communication difficulties b. Personality changes c. Impaired memory d. Separation from others
c. Impaired memory Patients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. They also exhibit impulsivity, which increases their risk. Maintaining a safe environment takes top priority. Communication difficulties could be the basis for several nursing diagnoses such as impaired verbal communication, powerlessness, and impaired social interaction. Separation from others could lead to social isolation, impaired social interaction, and social isolation. Personality changes may lead to a risk for self- or other directed violence, chronic low self-esteem, and risk for suicide.
A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? a. Keep the eyes closed for 1 to 2 minutes after administration. b. Apply the medication evenly to the sclera c. Instill the medication in the conjunctival sac. d. Maintain a supine position for 10 minutes after administration.
c. Instill the medication in the conjunctival sac. 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.
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside? a. Nebulizer and thermometer b. Incentive spirometer c. Intubation tray and suction apparatus d. Blood pressure apparatus
c. Intubation tray and suction apparatus Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.
Some clients with acoustic neuromas have vertigo. What is a priority nursing action for clients with vertigo? a. Mobilize the client at every opportunity. b. Provide small meals of tepid food. c. Protect the client from injury. d. Provide ice to the affected ear.
c. Protect the client from injury. For clients with vertigo, the nurse takes measures to protect the client from injury. Nursing actions do not include providing small meals of tepid food, mobilizing the client at every opportunity, or providing ice to the affected ear.
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? a. Help the client complete his or her sentences as needed. b. Speak in a loud and deliberate voice to the client. c. Provide a board of commonly used needs and phrases. d. Have the client speak to loved ones on the phone daily.
c. Provide a board of commonly used needs and phrases. The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.
A client with Meniere's disease has a nursing diagnosis of risk for injury related to gait disturbances and vertigo. Which of the following would be most appropriate to include in this client's plan of care? a. Moving the head from side-to-side when vertigo occurs b. Performing self-care activities when the vertigo first starts c. Sitting down at the first signs of feeling dizzy d. Closing the eyes when lying down during an episode of vertigo
c. Sitting down at the first signs of feeling dizzy For a nursing diagnosis of risk for injury, the client should sit down at the first sign of feeling dizzy. The client also should place a pillow on each side of the head to avoid movement, keep the eyes open, and stare straight ahead when lying down and perform self-care activity during vertigo-free periods.
The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client? a. To minimize the risk of a tumor that involves the vestibulocochlear nerve b. To minimize the adverse effects of drug therapy c. To reduce the production of fluid in the inner ear d. To reduce the magnitude of the hearing deficit
c. To reduce the production of fluid in the inner ear A low-sodium diet lessens edema. This measure does not help minimize the adverse effects of drug therapy, reduce the magnitude of the hearing deficit, or minimize the risk of a tumor that involves the vestibulocochlear nerve.
A client at an extended-care facility who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include a. Having the client sit at the nurse's station during night-time hours b. Providing a glass of warm milk for breakfast c. Walking the client in the facility yard during the day d. Allowing the client to take a 2-hour nap in the afternoon
c. Walking the client in the facility yard during the day Regular exercise during the day will enhance sleep at night for clients with Alzheimer's disease. Another activity that helps for interrupted sleep, inability to fall asleep, or both is drinking warm milk at night. The nurse should discourage excessive sleep during the day. Sitting at the nurse's station may be too stimulating at night-time hours.
A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? a. "The numerous drugs that he was taking contributed to his current confusion." b. "A specific gene is involved in the development of this disorder." c. "This condition is most likely due to a stroke that the patient didn't realize he had." d. "Evidence shows that there are changes in nerve cells and brain chemicals."
d. "Evidence shows that there are changes in nerve cells and brain chemicals." Specific neuropathologic and biochemical changes are found in patients with Alzheimer's disease. These include neurofibrillary tangles and neuritic plaques as well as altered neurotransmitter function, specifically acetylcholine. Vascular dementia is associated with a subclinical stroke. Although genetics is being studied as an underlying mechanism for Alzheimer's disease, no specific gene or genetic marker has been identified. Delirium is often the result of the interaction or use of multiple drugs.
An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? a. "What concerns you most about Alzheimer disease?" b. "Alzheimer disease can be a great burden on the family. What community resources do you know about?" c. "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever." d. "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."
d. "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." Delirium is associated with a sudden onset of confusion, not Alzheimer disease. The family needs to be told the correct information, which is that several underlying conditions could be causing the confusion. Once the underlying cause(s) is found and treated, the confusion should subside; however, some clients may not recover from the underlying cause, so telling the family the client will be better than ever is not appropriate. Asking the family about their concerns about Alzheimer disease and what they know about community support related to it is not appropriate because the client is exhibiting symptoms related to delirium.
The nurse is teaching the client to instill eye drops. Which statement is correct? a. "Eye drops are to be administered after eye ointments." b. "Wait 10 minutes between administering different eye ointments; you do not need to wait between administering different eye drops." c. "Eye drops may be administered with contact lenses in place." d. "Wash your hands before and after instilling eye drops and do not touch the tip of the bottle."
d. "Wash your hands before and after instilling eye drops and do not touch the tip of the bottle." Eye medications should be administered using an aseptic technique. Therefore, handwashing and not contaminating the tip of the medication container is important. Eye drops are administered after eye ointments, not before. The waiting time between administering eye ointments is 10 minutes. The client should also be taught to wait 5 minutes between the instillation of different eye drops. Contact lenses should be removed before eye drops or ointment is applied.
A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to a. Encourage the mother to take responsibility for cooking and cleaning the house. b. Allow the mother to smoke cigarettes outside on the porch without supervision. c. Turn off lights at night so that the mother differentiates night and day. d. Ensure that the mother does not have access to car keys or drive an automobile.
d. Ensure that the mother does not have access to car keys or drive an automobile. A person with Alzheimer's disease needs to be provided with a safe environment. Driving is prohibited. Cooking and cleaning may be too much stimulation and place the client in danger. Daily activities must be simplified, short, and achievable. Smoking is allowed only with supervision. The person needs adequate lighting, and nightlights are helpful, particularly if the person has increased confusion at night.
A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the client's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the client's plan of care? a. Elevate the head of the bead to 75 degrees b. Leg exercises to prevent DVT c. Administer enemas when the client is constipated d. Maintain the client on complete bed rest
d. Maintain the client on complete bed rest Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. No enemas are permitted, but stool softeners and mild laxatives are prescribed. Thigh high elastic compression stockings or sequential compression boots may be ordered to decrease the patient's risk for deep vein thrombosis (DVT).
You are admitting a 30-year-old who has a hearing impairment. The client is accompanied by family members. What information would be important to ask the family members to help you care for your client? a. How the client lost their hearing b. How much the client weighs c. What allergies the client has d. The client's preferred method of communication
d. The client's preferred method of communication Some clients with hearing deficits learn sign language, a method for communication that uses a hand-spelled alphabet and word symbols. Clients also learn speech reading, also called lip reading. Knowing when the client lost their hearing, or what allergies the client has or how much the client weighs will not help you communicate, thereby, care for the client better.
A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse? a. Change the dressing while the patient is reading the steps of the treatment because distraction decreases anxiety. b. Use nonverbal signals of agreement (head nodding), even if unsure, to instill confidence and trust. c. Minimize misunderstandings by completing the patient's sentences (e.g., fill-in-the-blanks) to decrease the patient's embarrassment. d. Write down the steps of the procedure for the patient to read before beginning the treatment.
d. Write down the steps of the procedure for the patient to read before beginning the treatment. Written communication is an excellent resource and means of mutual understanding. Distraction is not appropriate because a hearing-impaired person needs the care provider's full attention. Do not pretend to understand or complete the person's sentences for them.
A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should: a. ask the physician to order restraints to prevent wandering. b. ask the physician to order sedation to allow the client to rest. c. have the client wear two briefs at a time to ensure absorption of incontinent urine. d. incorporate the client's toileting schedule into the pattern of his wandering.
d. incorporate the client's toileting schedule into the pattern of his wandering. Assists with elimination and increases the chance of continent episodes. Sedation and restraints will decrease the client's mobility but won't decrease the number of incontinent episodes. Wearing two briefs at a time won't ensure urine absorption and won't address the incontinence issue.
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply. 1. Becoming a burden on the family 2. Increasing disability 3. Loss of appetite 4. Possible nursing home placement 5. Pain associated with physical therapy
1. Becoming a burden on the family 2. Increasing disability 4. Possible nursing home placement Elderly clients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite.
An elderly client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which of the following symptoms to be exhibited in this client? Select all that apply. 1. Arcus senillis 2. Eye pain 3. Complete loss of vision in both eyes 4. Loss of central vision 5. Cobwebs in vision field 6. Flashing lights
5. Cobwebs in vision field 6. Flashing lights Many clients with detached retina experience a sensation of a curtain or veil lowering over vision field, flashing of lights, floaters, cobwebs, or spots. Complete vision loss can occur in the affected eye. Loss of central vision, eye pain, and arcus senilis is not indicated in this disorder.
A client diagnosed with a cataract comes into the clinic. What assessments should the nurse observe in this client? a. Inability to produce sufficient tears b. A swollen lacrimal caruncle c. A burning sensation and the sensation of an object in the eye d. Blurred or cloudy visual image
d. Blurred or cloudy visual image 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 developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care? a. Restrict high-potassium foods. b. Administer prescribed antihistamine. c. Encourage intake of caffeinated fluids. d. Limit foods that are high in sodium.
d. Limit foods that are high in sodium. Sodium and fluid retention disrupts the delicate balance between the endolymph and perilymph in the inner ear. Therefore, many clients can control their symptoms by adhering to a low-sodium diet. Caffeinated fluids are to be avoided because of their diuretic effect. Diuretics, not antihistamines, would be prescribed to lower the pressure in the endolymphatic system. Foods high in potassium would be encouraged if the client is prescribed a diuretic that causes potassium loss.
A patient is being seen in the ophthalmology clinic for a suspected detached retina. What clinical manifestations does the nurse recognize as significant for a retinal detachment? Select all that apply. 1. A visual field of floating particles 2. Pain 3. Momentary flashes of light 4. A definite area of blank vision 5. Halos around the eyes
1. A visual field of floating particles 3. Momentary flashes of light 4. A definite area of blank vision Patients 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 not complain of pain. Halos around the eyes are associated with glaucoma, not retinal detachment.
A patient presents to an eye clinic with a number of symptoms related to his diminished vision. An initial history leads the nurse practitioner to suspect that the patient has acute angle-closure glaucoma. Which of the following symptoms would apply to this diagnosis? Select all that apply. 1. Gradual loss of peripheral vision 2. Sudden onset of visual disturbance 3. Nausea and vomiting 4. Severe eye pain 5. Reddening of the eye 6. Tunnel vision
2. Sudden onset of visual disturbance 3. Nausea and vomiting 4. Severe eye pain 5. Reddening of the eye Gradual loss of peripheral vision, usually in both eyes, and tunnel vision in advanced stages are symptoms of primary open-angle glaucoma.
A client has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action? a. Reassure the client that this is an age-related change in vision. b. Arrange for the client to be assessed for macular degeneration. c. Facilitate tonometry testing. d. Arrange for the client to have her visual acuity assessed.
d. Arrange for the client to have her visual acuity assessed. The Amsler grid is a test often used for clients with macular problems, such as macular degeneration. Distortions would not be attributed to age-related changes and there is no direct need for testing of intraocular pressure or visual acuity.
A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? a. Flexor spasm, clonus, and negative Babinski reflex b. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs c. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes d. Blurred vision, intention tremor, and urinary hesitancy
d. Blurred vision, intention tremor, and urinary hesitancy Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski reflex is found in MS. Abdominal reflexes are absent with MS.
A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include? a. "The drug helps to control the symptoms of the disease." b. "Once it becomes effective, you can stop the drug." c. "This drug will help to stop the disease from getting worse." d. "The client need to take this drug for the rest of his or her life."
a. "The drug helps to control the symptoms of the disease." Donepezil hydrochloride is a cholinesterase inhibitor used to control symptoms of Alzheimer's disease. It does not cure or slow progression. Typically cognitive ability improves within 6 to 12 months of therapy, but if stopped, cognitive progression occurs. It is recommended that treatment continue at least through the moderate stage of the illness. However, it usually is not prescribed as life-long therapy.
The nurse should recognize the greatest risk for the development of blindness in which of the following clients? a. A 58-year-old Caucasian woman with macular degeneration b. A 28-year-old black man with myopia c. A 28-year-old Caucasian man with astigmatism d. A 58-year-old black woman with hyperopia
a. A 58-year-old Caucasian woman with macular degeneration The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts. The 58-year-old Caucasian woman with macular degeneration has the greatest risk for the development of blindness related to her age and the presence of macular degeneration. Individuals with hyperopia, astigmatism, and myopia are not in a risk category for blindness.
A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to: a. wander. b. not change his position often. c. forget to eat. d. exhibit acquiescent behavior.
a. wander. A client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing him closer to the nurses' station makes it easier to monitor him and better ensures his safety if he begins to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change his position often, or modify his behavior.
A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding? a. "I need to call the doctor if I have a light morning discharge." b. "I need to call the doctor if I get nauseated." c. "I need to call the doctor if I see flashing lights." d. "I need to call the doctor if I get a scratchy feeling."
c. "I need to call the doctor if I see flashing lights." Postoperatively, the client who has undergone cataract extraction with intraocular lens implant should report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the ophthalmologist. Slight morning discharge and a scratchy feeling can be expected for a few days. Blurring of vision may be experienced for several days to weeks.
Nursing students are reviewing statistics related to the older adult population and leading causes of death in this age group. The students demonstrate understanding of this information when they rank the following conditions in the order from highest to lowest. 1. Diabetes 2. Malignant neoplasms 3. Chronic obstructive pulmonary disease 4. Cerebrovascular disease 5. Heart disease 6. Alzheimer's disease
1. Heart disease 2. Malignant neoplasms 3. Cerebrovascular disease 4. Chronic obstructive pulmonary disease 5. Alzheimer's disease 6. Diabetes According to the National Center for Health Statistics, the leading causes of death in the older adult from highest to lowest are heart diseases, malignant neoplasms, cerebrovascular disease, chronic obstructive pulmonary disease, Alzheimer's disease, and diabetes.
A client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note? Select all that apply. 1. Visual changes 2. Sensory loss 3. Vomiting 4. Muscle weakness 5. Aphasia
1. Visual changes 2. Sensory loss 4. Muscle weakness 5. Aphasia Common focal, or localized, symptoms include muscle weakness, sensory loss, aphasia, and visual changes. When specific regions of the brain are affected, additional local signs and symptoms occur, such as motor abnormalities, changes in hearing, alterations in cognition, and language disturbances. Vomiting would be considered a generalized symptom.
A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. 1. Obtain a blood type and cross-match 2. Administer antipyretics as prescribed 3. Place the client in positive pressure isolation 4. Monitor pain levels and administer analgesics 5. Perform frequent neurologic assessments
2. Administer antipyretics as prescribed 4. Monitor pain levels and administer analgesics 5. Perform frequent neurologic assessments Clients with meningitis require antipyretics and analgesia to treat fever and pain. As well, their neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised.
Postoperative health teaching for a patient who has had an intraocular lens implant is a vital nursing responsibility. Which of the following statements applies to this situation? Select all that apply. 1. Avoid lying on the side of the affected eye for 72 hours. 2. Avoid bending the head forward for an extended time. 3. Wipe the closed eye from the inner canthus outward 4. Do not lift, pull, or push objects heavier than 15 pounds. 5. Avoid shampooing your hair for 48 hours.
2. Avoid bending the head forward for an extended time. 3. Wipe the closed eye from the inner canthus outward 4. Do not lift, pull, or push objects heavier than 15 pounds. Hair shampooing may resume in 24 hours, if done cautiously. It is only necessary to avoid lying on the side of the affected eye for the first night after surgery.
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? a. Respiratory b. Gastrointestinal c. Skin d. Urinary
a. Respiratory Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency.
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? a. "The most common cause of dementia in the elderly is Alzheimer's disease." b. "Dementia is a terrible disease of the elderly." c. "Depression may manifest as dementia in elderly clients." d. "Drug interactions are the most common cause of dementia in the elderly."
a. "The most common cause of dementia in the elderly is Alzheimer's disease." The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's disease. Depression is common in elderly clients, but it doesn't cause dementia.
The nurse is providing a health promotion session on the risk factors for various health conditions. When discussing brain tumors, the nurse should include in the session which known risk factors for brain tumors? Select all that apply. 1. Cigarette smoking 2. Exposure to certain chemicals 3. Having ionizing radiation 4. Living close to power lines 5. Cell phone use
2. Exposure to certain chemicals 3. Having ionizing radiation During this health promotion session, the nurse should be discussing known risk factors for brain tumors, of which there are only two; exposure to cancer-causing chemicals and ionizing radiation. The factors listed in the alternate options are undergoing further investigation and, although research is finding correlations between these factors and brain tumors, further investigation is still required.
Which type of glaucoma presents an ocular emergency? a. Ocular hypertension b. Acute angle-closure glaucoma c. Chronic open-angle glaucoma d. Normal tension glaucoma
b. Acute angle-closure glaucoma 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.
A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds: a. "What precipitates the outbursts?" b. "You need to remain calm during the outbursts." c. "Play quiet music that your grandmother may like." d. "Start rubbing her shoulders and her back."
a. "What precipitates the outbursts?" A client with Alzheimer's disease may respond to exciting or confusing events with a catastrophic reaction, such as screaming, crying, or becoming abusive. The nurse needs to assess the situation and what precipitates the catastrophic reactions to best address how to prevent these events. Other nursing interventions include telling the client's granddaughter to remain calm and to distract the grandmother with quiet music, stroking, or both.
