Fundamentals Exam 2

A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is​ best? A. ​"There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent​ them." B. ​"The nurses here are safe. The posters are directed at certain members of the healthcare team who have been making more mistakes than​ usual." C. ​"You don't need to worry about posters on the wall. Our primary concern is getting you​ well." D. ​"We never make mistakes here. We want the public to know that we have client safety goals​ here."

A Client safety initiatives address collaborative efforts by staff and clients to promote safety in healthcare settings. These initiatives require collaboration by all members of the​ team, including clients. Mistakes can occur in all healthcare​ settings; behaviors, not​ goals, help to prevent them.

A nurse is planning an​ in-service on preventing infection for the staff nurses on a​ hospital's medical-surgical unit. Which of the following should be the priority teaching point for this​ in-service? A. Performing hand hygiene B. Raising the temperature in each​ client's room C. Wearing a mask for client care D. Assessing vital signs once daily

A Hand hygiene is always the first and best way to stop the spread of​ microorganisms, which cause infections. Raising the temperature in a​ client's room would contribute to the growth of microorganisms. Assessing vital signs is important but should be done more frequently than once daily. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.

The nurse is planning care for an adolescent client recently diagnosed with​ Charcot-Marie-Tooth syndrome. Which intervention is the highest​ priority? A. Reducing the​ client's risk for injury B. Relaxing the client to reduce stress C. Addressing the​ client's perfusion problems D. Managing the​ client's chronic pain

A In the early stage of​ Charcot-Marie-Tooth syndrome, the disease may manifest in clumsiness due to foot drop and muscle weakness in the​ feet, ankles, and​ legs, so addressing risk for injury is the priority for this client. As the client​ ages, chronic pain will likely become a​ concern, but not likely at this stage in the disease. Addressing problems with perfusion would not be the priority​ here, and even if the client feels​ stress-induced anxiety because of the​ illness, that is not a priority over ensuring the safety of the client.

Which assessment finding is consistent with a diagnosis of​ open-angle glaucoma? A. A client experiences gradually diminishing vision in both eyes over an extended period. B. A client loses vision intermittently several times over the course of several hours. C. A client has an episode of lost vision when experiencing a panic attack. D. A client loses the ability to see at all during a​ city-wide blackout.

A Open-angle glaucoma tends to be a chronic and gradually progressive disease. It typically affects both​ eyes, although the pressures and progression may not be symmetric. Patients with​ angle-closure glaucoma may have intermittent episodes lasting several hours before they have a more typical prolonged attack of​ angle-closure glaucoma. Because of the effect of pupil dilation on aqueous outflow in​ angle-closure glaucoma, episodes often occur in association with​ darkness, emotional​ upset, or other factors that cause the pupil to dilate.

A client with a long history of type 2 diabetes mellitus complains of occasional coldness and numbness in both hands and both feet. These complaints are suggestive of which​ condition? A. Polyneuropathy B. Mononeuropathy C. Idiopathic peripheral neuropathy D. Hereditary peripheral neuropathy

A Polyneuropathies, the most common types of neuropathy associated with​ diabetes, are bilateral sensory disorders. The manifestations appear first in the toes and feet and progress upward. The fingers and hands also may be​ involved, but usually only in later stages of diabetes. Mononeuropathies are isolated and affect only single​ nerves; they are commonly associated with injury or trauma. An idiopathic peripheral neuropathy would have no known​ cause, but for this client diabetes would be a likely cause of​ neuropathy, and diabetes is not​ hereditary, so there is no reason to suspect hereditary peripheral neuropathy.

Which client is most at risk for eye​ injuries? A. A baseball player who wears nothing over the eyes B. A construction worker who wears​ OSHA-required eyewear at all times while on site C. A firefighter who wears all required safety gear on calls D. A​ self-employed home worker who wears ANSI Z87 eyewear when doing any household cleaning or yard work

A Protective eyewear is estimated to prevent more than​ 90% of all​ injuries, but more than​ 78% of individuals with eye injuries reported not wearing eyewear at the time of injury. Based on this​ data, the baseball player is most at risk for eye injuries because of the lack of eye protection and the potential for getting hitting in the face with a ball. Although the firefighter and construction workers are in more dangerous lines of​ work, they are also taking the required steps to protect their eyes and so are less at risk. The home worker is likely to be at least risk for eye injuries and yet still uses appropriate eyewear when cleaning or doing yard work.

After completing an​ assessment, the nurse determines a client is at risk for safety issues. Which data supports the​ nurse's conclusion? A. Occasional dizziness with walking B. Follows a vegetarian diet C. Lives with adult married daughter and family D. Receives an annual ophthalmologic examination

A Risks to safety include factors that can impact falls such as mobility issues or balance. Living with​ family, eating a vegetarian​ diet, and having annual eye examinations do not increase the​ client's risk for safety issues.

Which of the following scenarios is consistent with secondary congenital​ glaucoma? A. A​ 1-year-old infant develops glaucoma following neurofibromatosis. B. A newborn is diagnosed with glaucoma at birth. C. A​ 5-year-old child is diagnosed with glaucoma. D. An infant is diagnosed at 6 months with glaucoma.

A Secondary congenital glaucoma results from disorders of the eye or the​ body, including​ Sturge-Weber syndrome,​ Axenfeld-Rieger syndrome,​ aniridia, and​ neurofibromatosis, so the​ 1-year-old infant who develops glaucoma following neurofibromatosis has secondary congenital glaucoma. The newborn diagnosed at birth with glaucoma has congenital​ glaucoma, the infant diagnosed at 6 months has infantile​ glaucoma, and the child diagnosed at 5 years has juvenile glaucoma.

A school nurse is identifying students who may have hearing loss. Which student would the nurse be most concerned​ about? A. A child who cannot follow conversations in the hallways between classes or in the cafeteria B. A child who gets annoyed when things like televisions are too loud C. A child who likes to listen to music on earbuds D. A child who startles easily at loud noises

A The child who cannot follow conversations in the hallways between classes or in the cafeteria appears to be having trouble understanding speech when background noise is​ present, which is a sign that the child may require further evaluation for hearing loss. A child not startling at loud noises would be a sign of hearing loss. A child who gets annoyed when electronic devices are too loud or who likes to listen to music on earbuds is behaving normally.

The nurse is providing teaching to a client at risk for acquired peripheral neuropathy. Which of the following activities should the nurse suggest the client modify or avoid to reduce the risk of this​ condition? A. Drinking one​ six-pack of beer per day B. Typing on the computer for several hours each day C. Playing tennis every Saturday D. Working as an automobile mechanic on weekends

A The client has a daily alcohol intake of one​ six-pack of beer. Alcohol abuse is a risk factor for the development of acquired peripheral​ neuropathy, so the client should be discouraged from drinking. Typing on the computer for several hours each day might cause some localized nerve compression in the wrists but would not contribute to peripheral neuropathy. Working as an automobile mechanic and playing tennis would not cause peripheral neuropathy.

The nurse is caring for a client who has been using timolol​ (Timoptic) to manage glaucoma. Which assessment finding supports an adverse effect associated with systemic absorption of the​ drug? A. Heart rate of 57 B. Urinary frequency C. Blurred vision D. Eye pain

A The onset of bradycardia must be evaluated. Timoptic is a​ beta-adrenergic blocker. It is associated with bradycardia in some clients. Frequent urination is associated with the use of carbonic anhydrase inhibitors. Eye pain and dim or blurred vision are associated with the use of miotic medications.

The nurse is providing teaching to an older adult client related to avoiding eye injury. What should the nurse identify as an intervention to address the​ number-one cause of eye injuries in older​ adults? A. Addressing slippery floors and other fall hazards in the​ client's home B. Storing all harsh chemicals out of easy reach C. Turning down the temperature of the​ client's home water heater D. Ensuring the client wears protective goggles when engaging in outdoor activities

A The​ number-one cause of eye injury in older adults is falling. Primary causes of falls in older adults include slipping on wet surfaces and falling down​ stairs, so addressing fall hazards such as slippery floors would best prevent eye injuries for this client. Ensuring an appropriate water heater temperature would prevent scalds but does not specifically address risk of eye injury. Wearing eye protection is a good idea when participating in certain​ sports, but it is not necessary at all times and does not reduce the risk of​ fall-related injuries. Storing chemicals out of reach is probably not necessary unless there are children in the​ home; furthermore, keeping chemicals in a place that requires use of a stepstool or ladder may actually increase an older​ adult's risk of falls.

The nurse is assessing a client who is recovering following surgery. Which factor would increase this​ client's susceptibility to​ infection? A. Presence of an incision B. Intact mucous membranes C. Active bowel sounds D. Dry skin

A This client has a surgical​ incision, so the​ body's first line of​ defense, the​ skin, is not intact. Active bowel​ sounds, dry​ skin, and intact mucous membranes are factors that help defend the body against infection.

Which of the following best describes​ tinnitus? A. Auditory perception without external auditory stimuli B. Lack of auditory perception of external auditory stimuli C. A ringing sound accompanying perception of​ high-frequency tones D. Auditory perception from visual stimuli

A Tinnitus is the perception of sound or noise in the ears without stimulus from the environment. The sound may be​ steady, intermittent, or pulsatile and is often described as a​ buzzing, roaring, or ringing. It would not be ringing accompanying the perception of​ high-frequency tones because such a perception would involve external auditory stimuli. Lack of auditory perception of external auditory stimuli is lack of hearing. Tinnitus does not involve perception of visual stimuli as auditory.

Which nursing action is most appropriate when communicating with a client who has a hearing​ deficit? A. Writing ideas or pantomiming as appropriate in order for the client to understand B. Using shorter​ phrases, which tend to be easier to understand than longer ones C. Drawing out the articulation of words with extra emphasis in order for the client to understand D. Varying the volume of​ voice, which is easier to understand than one consistent volume

A Writing ideas and pantomiming as appropriate are acceptable forms of communication for a client who has a hearing deficit. The nurse should not overarticulate​ words, use short​ phrases, or vary the volume of voice because these things make it more difficult to understand for the client with a hearing deficit.

Which actions should the nurse take to help the client with bowel and bladder dysfunction reduce the risk of​ infection? Select all that apply. A. Monitor intake and output. B. Use standard precautions when handling linen after episodes of incontinence. C. Provide hygienic care after episodes of incontinence. D. Limit fluid intake. E. Isolate the client using​ transmission-based precautions.

A B C Monitoring intake and output is important because it can help reveal whether a client is experiencing dehydration. Dehydration may lead to urinary​ stasis, which increases the risk of infection.​ Similarly, intake and output levels can help reveal urinary​ retention, which also heightens the risk of infection. Providing hygienic care after episodes of bowel or bladder incontinence will ensure that the skin remains​ intact, reducing the risk of infection. Using proper biohazard precautions after episodes of incontinence will also reduce the risk of transmitting an infection. In​ contrast, limiting fluid intake increases infection risk by putting the client at greater risk for dehydration. Isolating the client using​ transmission-based precautions is not necessary because these precautions are meant to prevent the spread of infection from the client to​ others, and this client is not currently experiencing infection.

A client is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this​ client? Select all that apply. A. Monitor for allergic reaction. B. Assess renal and liver function. C. Monitor vital signs. D. Encourage adequate fluid intake. E. Assess pain level.

A B C D Nursing interventions to support antibiotic therapy include encouraging adequate fluid​ intake, monitoring for manifestations of an allergic​ reaction, assessing renal and hepatic​ function, and assessing vital signs. Although some clients may experience pain related to staph​ infection, antibiotics do not address​ pain, so assessment of pain levels is not related to administration of these medications.

The home care nurse is assessing a client with macular degeneration. What interventions would be appropriate to ensure home safety for this​ client? Select all that apply. A. Keep the stairs free of clutter. B. Remove scatter rugs from the floors in the home. C. Use one electrical outlet for devices. D. Have grab bars installed in the bathroom. E. Wear socks without shoes when walking in the home.

A B D The client with macular degeneration is at risk for injury. To reduce this​ risk, the nurse should instruct and plan to help the client remove scatter rugs from the floors in the​ home, have grab bars installed in the​ bathroom, and keep the stairs free of clutter. The client should not walk without proper footwear. Using one electrical outlet in the home could cause an electrical hazard.

The nurse is caring for a client who is exhibiting signs of a systemic infection following surgery. Which diagnostic tests would the nurse anticipate being​ ordered? Select all that apply. A. Urinalysis B. White blood cell differential C. Serum electrolyte levels D. White blood cell count E. Wound culture

A B D E Serum electrolyte levels are not used to determine the presence of a systemic infection. Urinalysis is used to assess for the presence of bacteria or blood in the urine. An elevated WBC and​ 15% bands are indicative of an infection. Wound cultures are used to identify probable microorganisms.

The healthcare provider prescribes a client to have peak and trough blood levels drawn to evaluate the therapeutic effect of an IV antibiotic. When should the nurse schedule the blood samples to be​ drawn? Select all that apply. A. 30 minutes after the IV administration B. During the infusion of the antibiotic C. A few minutes before the next scheduled dose of medication D. 1 to 2 hours after the oral administration of the medication E. Prior to the discontinuing the antibiotic

A C Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range-that ​is, the minimum and maximum blood levels at which the drug is effective-is known for a given drug. By measuring blood levels at the predicted peak​ (1-2 hours after oral​ administration, 1 hour after intramuscular​ administration, and 30 minutes after IV​ administration) and​ trough, usually a few minutes before the next scheduled​ dose, it is also possible to determine whether the drug is reaching a toxic or harmful level during​ therapy, increasing the likelihood of adverse effects.

An older adult client is using prescription eyedrops to treat her glaucoma. When providing client teaching about this​ medication, which of the following should the nurse mention as potential side​ effects? Select all that apply. A. Blurred vision B. Headaches C. Change in eye color D. Intermittent loss of eyesight E. Clouding of the eyes

A C The client is taking a prostaglandin analog as​ eyedrops, which can cause the side effect of a change in iris color. Other potential side effects are blurred​ vision, eye pain​ (itching, burning,​ stinging), and eye​ redness, but not intermittent eyesight​ loss, headaches, or clouding of the eyes.

A client comes into the emergency department with an eye injury. Which assessment findings suggest that this injury is the result of blunt​ trauma? Select all that apply. A. Lid ecchymosis B. A feeling of something in the eye C. Eye pain and decreased sharpness of vision D. A​ well-defined bright area of erythema under the conjunctiva E. Photophobia and eye tearing

A C D Blunt trauma to the eye can cause lid​ ecchymosis, or a black​ eye, and subconjunctival​ hemorrhage, which would be indicated by a​ well-defined bright area of erythema under the conjunctiva. Decreased visual acuity​ (sharpness of​ vision) and eye pain can occur because of​ trauma-related hyphema, or bleeding into the anterior chamber of the eye. A feeling of something in the eye is typically caused by a foreign body on the conjunctiva. Photophobia and eye tearing are most often seen in corneal​ abrasions, not blunt trauma.

The nurse is planning instruction for a client who is newly diagnosed with glaucoma. What should be included in this​ teaching? Select all that apply. A. Attend​ follow-up appointments with the physician. B. Clouding of the affected​ eye(s) is expected. C. ​Self-administer prescribed eye medication properly. D. Manage eye pain with​ over-the-counter analgesics. E. Avoid​ over-the-counter medication unless discussed with the physician.

A C E When instructing a client on how to manage the diagnosis of​ glaucoma, the nurse should include why the client needs to avoid​ over-the-counter medication unless discussed with the​ physician, the method to​ self-administer prescribed eye​ medication, and the importance of attending​ follow-up appointments with the physician. Eye pain or clouding of affected eyes is not to be expected and should be reported to the physician.

Which practices support promotion of health​ safety? Select all that apply. A. Exercise every day B. Eliminate all foods containing fat C. Only see healthcare providers when sick D. Avoid driving when sleepy or tired E. Wear seat belts

A D E Health promotion involves many different​ practices, including staying physically​ active, following guidelines for motor vehicle​ safety, eating an appropriate​ diet, and monitoring personal health status. Eliminating all foods containing fat would eliminate necessary nutrients from the​ diet, and clients should see a healthcare provider at least annually for a checkup even if not sick.

The nurse is caring for a client in the early stage of macular degeneration. What dietary changes should the nurse recommend to slow the progression of the​ disease? A. ​Low-fat diet B. ​High-antioxidant diet C. ​Low-antioxidant diet D. ​High-fat diet

B A diet high in antioxidants-such as​ fish; green, leafy​ vegetables; copper; and zinc-has been shown to slow the progression of macular degeneration in its early to intermediate stage when it is nonexudative. Neither​ low- nor​ high-fat diets slow the progression of macular degeneration.

The nurse is providing teaching on the recommended hearing tests for older adults. Which information should be included in this​ teaching? A. Annual screenings are recommended for adults with diabetes. B. Have a hearing test every 10 years until age 50 and then every 3 years. C. Schedule an annual hearing test until the age of 50 and then have a test every 6 months. D. For individuals without​ comorbidities, hearing exams should be repeated every​ 1-3 years for ages​ 55-64, and every​ 1-2 years for ages 65 and above.

B Adults should be screened for hearing at least every 10 years until the age of 50 and then every 3 years. A biannual or annual hearing test is not necessary for this age group. Annual screenings for vision are recommended for adults with​ diabetes, and for individuals without​ comorbidities, eye exams should be repeated every​ 1-3 years for ages​ 55-64, and every​ 1- years for ages 65 and above.

Which assessment finding supports the​ nurse's conclusion that a client is at risk for​ cataracts? A. Hypertension B. Age 75 years C. Moderate alcohol use D. Smoker

B Age is the greatest single risk factor for cataracts. Environmental and lifestyle​ factors, such as​ long-term exposure to​ sunlight, increase the risk for​ cataracts; cigarette smoking and heavy alcohol consumption are associated with earlier cataract development. This​ client's age would indicate a predisposition for cataract​ formation, but not hypertension or only moderate alcohol use. Being a smoker would indicate such a​ predisposition, but this is still not as great a risk factor as the​ client's age.

The nurse is providing teaching to a client who was prescribed an ophthalmic beta blocker for glaucoma. The client is having difficulty understanding how to​ self-administer the medication. Which instruction by the nurse is​ best? A. ​"Occlude your lacrimal​ duct." B. ​"Close your​ eyes." C. ​"Use punctal​ occlusion." D. ​"Guard against systemic​ absorption."

B Because systemic absorption may occur with beta​ blockers, the nurse should teach the client to close the eyes and occlude the lacrimal duct after administration to help reduce systemic absorption. The simplest way to provide this teaching in a way the client will readily understand is by instructing the client to close the eyes. Using terms such as​ "occlude your lacrimal​ duct," "guard against systemic​ absorption," or​ "use punctal​ occlusion" require additional explanation to be properly understood by the client.

Which agent can be used to destroy pathogens other than​ spores? A. Sterilizing agent B. Disinfectant C. Antiseptic D. Isolating agent

B Disinfectants destroy pathogens other than spores. Antiseptics only inhibit the growth of some organisms. A sterilizing agent destroys all​ pathogens, including spores. Isolation is used to prevent the spread of infection but does not destroy any pathogens.

A nurse is evaluating the care received by a client who has a hearing deficit. Which statement indicates that the client is effectively addressing variables that may lead to social​ isolation? A. ​"I might use the hearing aid when I go​ shopping." B. ​"I ask others to face me when they talk because I can hear them​ better." C. ​"I don't use my hearing aid unless someone seems to need to talk to​ me." D. ​"I keep the television volume raised to a high​ level."

B Evidence that the client is effectively addressing variables that may lead to social isolation would include the​ client's account of asking others to face him or her when talking. This indicates that the client is taking an active role in improving communication with others. Clients should be encouraged to interact with friends and family on a​ one-to-one basis in quiet settings. Listening to a loud television at all times is not conducive to good communication. The other responses indicate a reluctance to use an assistive device unless​ necessary, which does not generally encourage social interaction.

Laser surgery and photodynamic therapy are both treatments for what disease of the​ eye? A. ​Age-related cataracts B. Exudative macular degeneration C. Nonexudative macular degeneration D. Congenital cataracts

B Exudative​ (wet) macular degeneration may be treated by laser surgery or photodynamic therapy. Macular degeneration of the nonexudative​ (dry) kind is treated with​ high-dose antioxidants and zinc. Neither laser surgery nor photodynamic therapy is used to treat​ age-related or congenital cataracts.

A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is​ priority? A. Remove the object. B. Stabilize the object. C. Apply eye ointment. D. Apply anesthetic drops

B For a severe or penetrating​ injury, promote rest and stabilize the injured eye by applying an eye pad or gauze dressing loosely over both the affected and unaffected eye. Stabilize any penetrating​ object, if possible. These measures reduce eye movement and can help preserve the​ client's vision. Anesthetic drops would be appropriate prior to the removal of a foreign body from the eye. Removal of a foreign body from the eye is​ appropriate, but not removal of a penetrating​ object, which could cause additional tissue damage. Use of eye ointment would be applicable after the removal of a foreign body or for a corneal abrasion.

A client is experiencing visual overstimulation. What can the nurse do immediately to reduce this​ client's visual sensory​ overload? A. Suggest the client wear sunglasses that block UVA rays only. B. Reduce the amount of light in the room by lowering shades and turning off overhead lights. C. Provide the client with​ large-print reading materials. D. Encourage the patient to employ relaxation techniques to reduce anxiety and stress.

B For clients who are at risk of​ overstimulation, nurses should assist with reducing the number and types of environmental stimuli. Appropriate measures for addressing visual overstimulation include lowering the shades and turning off overhead lights. Dark glasses that block both UVA and UVB rays are also useful. Relaxation techniques would be good for the client to employ but would require teaching for the client to properly implement them.​ Large-print reading materials would be helpful for a client with visual impairment but not a client who is experiencing visual sensory overload.

The nurse is evaluating instructions provided to a client with glaucoma. Which client statement indicates that teaching has been​ effective? A. ​"I will need to continually increase the dose of my​ eyedrops." B. ​"I must use my eyedrops as prescribed for the rest of my​ life." C. ​"I can stop the eyedrops when the glaucoma has​ resolved." D. ​"The eyedrops only need to be used when my eyes​ hurt."

B Glaucoma can be controlled but not​ cured; the client must use eyedrops for the rest of his life. Eyedrops must be used continuously as​ prescribed; most clients with glaucoma do not experience eye pain. Increasing the dosage of eyedrops is only necessary if the ocular pressure is not​ controlled; this must be determined by the healthcare​ provider, not the client.

Which is the decibel level for mild hearing​ loss? A. ​91+ dB B. ​16-40 dB C. ​71-90 dB D. ​41-70 dB

B Hearing loss is expressed in terms of​ decibels, or units of loudness.​ 41-70 dB is moderate hearing​ loss, at which most normal conversational sounds are missed.​ 16-40 dB is mild hearing​ loss, at which some speech sounds are difficult to perceive.​ 71-90 dB is severe hearing​ loss, at which speech sounds cannot be heard at a normal conversational level.​ 91+ dB is profound hearing loss and constitutes legal deafness.

Which of the following statements best describes the physiologic response of the layers of the eye in response to a penetrating​ injury? A. They degenerate and atrophy immediately. B. They reform following the penetration. C. They begin to tear away from one another. D. They pull away from the penetration.

B In a penetrating​ injury, the layers of the eye spontaneously reapproximate​ (join together) after entry of a​ sharp-pointed object or small missile​ (e.g., a​ BB) into the globe. They do not pull away from the​ penetration, immediately degenerate and​ atrophy, or begin to tear away from one another.

The nurse is conducting a prenatal assessment on a client. Which finding indicates a risk of sensory impairment in the unborn​ child? A. History of otitis media B. Lack of immunity to rubella C. Immunity to varicella D. Brief case of moderate conjunctivitis

B Maternal infection with rubella during pregnancy can cause vision impairment in newborns.​ Thus, lack of immunity to rubella indicates an increased risk of sensory impairment in the newborn. Immunity to varicella is a desirable trait that reduces a​ mother's chance of illness during​ pregnancy, thus lessening the likelihood of harm to the newborn. Sensory deficits resulting from maternal otitis media would not be hereditary.​ Conjunctivitis, or pink​ eye, is an infection that usually clears up on its own and is not congenital.

The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal​ detachment? A. Eye pain and redness B. Floaters in the visual field C. Hyphema D. Subconjunctival hemorrhage

B Of the choices​ listed, only floaters in the visual field are suggestive of retinal detachment. Eye pain and redness are not associated with retinal detachment. Although subconjunctival hemorrhage and hyphema may occur following a blow to the​ head, they are unrelated to detachment of the retina.

A client is receiving verteporfin treatment for macular degeneration. The client asks the nurse what the expected outcome of treatment is. Which response by the nurse is most​ appropriate? A. It will promote the development of new blood vessels. B. The progression of the disease will be slowed. C. It will increase the effectiveness of surgery. D. It will reverse the effects on the disease.

B One treatment for macular degeneration is the use of​ verteporfin, a drug that tends to adhere to the surface of new blood vessels. This medication is injected systemically. Light is then shined into the affected​ eye, activating the drug and destroying new blood vessels. The best outcome for this treatment is that it will slow the disease. This does not reverse the symptoms of the disease. New vessel growth is not desirable. The​ client's condition will be slowed at​ best; it is not likely to improve. Surgical therapy is rare as a treatment for AMD and this medication does not improve the efficacy of surgery.

A nurse is caring for a client with glaucoma who is prescribed an ophthalmic​ beta-adrenergic blocking agent. When teaching the client about the therapeutic action of this​ medication, which of the following statements should the nurse​ include? A. ​"Systemic absorption may​ occur, resulting in​ hypotension, bradycardia, and shortness of​ breath." B. ​"This drug reduces intraocular pressure by decreasing the production of fluid in the​ eye." C. ​"This drug reduces pressure in the eye by relaxing the muscles of the​ eye." D. ​"This medication only needs to be taken when eye pain is​ experienced."

B Ophthalmic​ beta-adrenergic blocking agents are one type of pharmacologic therapy used in the treatment of glaucoma. This class of medication works to reduce intraocular pressure by decreasing the production of aqueous humor in the ciliary body. Systemic absorption is a potential side effect of this type of​ drug, not the therapeutic action of the drug. This type of drug should be taken once or twice a​ day, not on​ as-needed basis when pain occurs. Relaxation of the ciliary muscle is an effect of prostaglandin analog​ drugs, another class of medications used in the treatment of glaucoma.

Where does​ perception, or the awareness and interpretation of​ stimuli, take​ place? A. The peripheral nervous system B. The brain C. The nerve receptors D. The impulses

B Perception, or awareness and interpretation of​ stimuli, takes place in the brain. The nerve receptors convert stimuli to impulses that travel along nerve pathways to the spinal cord or directly to the brain.

The nurse is identifying nursing diagnoses appropriate for a client with severe symptoms of​ tinnitus, vertigo, sensorineural hearing​ deficit, nausea, and vomiting. Which diagnosis would be the lowest priority for this​ client? A. Social Isolation B. Nausea C. Impaired Verbal Communication D. Risk for Injury

B Possible nursing diagnoses for the patient with hearing impairment may include Impaired Verbal​ Communication, Social​ Isolation, and Risk for Injury. Nausea is accurate for a client who has​ tinnitus, vertigo, and​ nausea; however, the greater priorities for this client would be safety related to​ falls, ensuring effective​ communication, and ensuring that the client does not become socially isolated.

The nurse is caring for a client with gangrene of the toe. Which collaborative intervention should the nurse anticipate preparing the client​ for? A. Wound irrigation B. Surgery C. Myringotomy D. Debridement

B Surgical intervention is the primary collaborative treatment for gangrene. Wound irrigation and debridement are used to remove dead tissue and debris from a wound. They are not used for gangrenous infections. Myringotomy is used to remove infected inner ear​ drainage, not for infected toes.

A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. Which tool should the nurse select to assess this​ client? A. Penlight B. Rosenbaum eye chart C. Snellen eye chart D. ​Cover-uncover test

B The Rosenbaum eye chart is used to test for near or reading vision. The Snellen chart is used to test far or distant vision. A penlight is used to test extraocular movements and pupillary response. The​ cover-uncover test is used to assess for eye muscle strength.

A client with peripheral neuropathy complains of leg aches and the inability to be comfortable. Which nursing diagnosis would be a priority for the client at this​ time? A. Ineffective Coping B. Chronic Pain C. Anxiety D. Ineffective Peripheral Tissue Perfusion

B The client reports aching legs and an inability to be comfortable. The nursing diagnosis most appropriate for the client at this time would be Chronic Pain. Ineffective Peripheral Tissue Perfusion is the likely reason for the​ client's pain and​ discomfort, but the​ nurse's primary interventions for this client will relate to pain​ management, safety, and​ comfort, not to directly treating the cause of the pain. The client may have anxiety and be coping​ ineffectively, but the diagnosis of Chronic Pain is the priority

Which of the following diagrams would the nurse use when describing​ open-angle glaucoma to a​ client? A. A diagram showing a blockage of the trabecular meshwork and canal of Schlemm B. A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm C. A diagram showing a completely occluded outflow of aqueous humor D. A diagram showing a completely closed anterior chamber angle

B The diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm demonstrates​ open-angle glaucoma. In​ open-angle glaucoma, the anterior chamber angle would be normal but outflow of aqueous humor would be​ reduced, although not to the degree that it was completely​ prevented, causing a rising intraocular pressure.

A nurse is caring for a client with a genetic nerve disorder who has difficulty when attempting to move her tongue. The nurse recognizes that this may indicate a deficit in the functioning of which cranial​ nerve? A. VI B. XII C. VIII D. XI

B The movement of the tongue for speech and swallowing is controlled by cranial nerve​ (CN) XII, hypoglossal. XI CN​ (accessory) controls the movement of head and neck as well as proprioception. CN VIII​ (acoustic/vestibulocochlear) controls hearing and the sense of balance. CN VI​ (abducens) control eyeball movement and moves eye laterally.

Which diagnostic test should the nurse use to assess hearing in an​ infant? A. Weber test B. Otoacoustic emissions test C. Whisper test D. Rinne test

B The otoacoustic emissions test uses an earphone and microphone to play sounds into the ear. Failure to detect an echo indicates hearing loss. This test is almost exclusively performed on infants as part of the routine hearing screening. The Rinne and Weber tests assess bone and air conduction with the use of a tuning fork. The whisper test provides a rough estimate of hearing loss. All three of these other tests involve active participation from the client.

The nurse is planning teaching for a client diagnosed with diabetic neuropathy. What should the nurse include in this​ teaching? A. Set the water heater at 120degreesF. B. Use a mirror to inspect feet daily. C. Increase medication for pain as necessary. D. Avoid hand and foot massages

B Using a mirror to inspect the feet daily is recommended because the client may not feel the formation of pressure​ points, blisters, or ulcers. Setting the water heater at 120degreesF is incorrect because it is too hot and the client may be scalded because of lack of sensation. Avoiding hand and foot massages is incorrect because this therapy will relax the​ client, increase the​ circulation, reduce the need for​ medication, and increase the psychologic benefits of​ touch, including the ability to be​ soothed, comforted,​ held, and loved. Increasing medication for pain as necessary is incorrect because it can further decrease touch sensation by clouding the sensorium and inducing​ lethargy, which requires additional supervision and monitoring to ensure safety.

The nurse is caring for a client who receives vitamin B12 injections to control her peripheral neuropathy. The client tells the nurse that she recently started experiencing increased tingling in her fingers and​ toes, and she asks the nurse what this means. How should the nurse​ reply? A. ​"The tingling is most likely unrelated to your​ injections." B. ​"The tingling suggests that you are due for another​ injection." C. ​"The tingling is a common side effect of B12​ injections." D. ​"The tingling means that the injections are not producing their intended​ effect."

B Vitamin B12 injections are given to reduce tingling related to peripheral neuropathy. A recent increase in tingling suggests that the medication has been working but the client is due for another injection soon.

The nurse is caring for a client who is being discharged following abdominal surgery with an incision. Which instruction is most important for the nurse to teach this client regarding wound​ healing? A. ​"Add more fruits and vegetables to your​ diet." B. ​"Thoroughly irrigate the wound with hydrogen peroxide once a​ day." C. ​"Notify the healthcare provider if you notice​ swelling, warmth, or tenderness at the wound​ site." D. ​"Apply a lubricating lotion to the edges of the wound twice a​ day."

C A client being discharged with a surgical wound has to be instructed on the detection of​ infection, as the skin is the first line of defense. Signs such as​ edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin​ C, which helps with wound​ healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating​ tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.

What does it mean to say that a corneal abrasion causes a disruption of the superficial epithelium of the​ cornea? A. The surface of the cornea sustains penetrating trauma. B. The superficial epithelium is completely removed. C. The integrity of the superficial epithelium is disturbed. D. Such injuries are typically painless.

C A disruption is a​ disturbance, in this case to the integrity of the superficial epithelium. An abrasion is not a penetrating injury. Objects that commonly cause corneal abrasion include contact​ lenses, eyelashes, small foreign bodies such as dust and​ dirt, and fingernails. Drying of the eye surface and chemical irritants also may result in a corneal abrasion. Superficial corneal abrasions typically heal quickly but are extremely painful. Completely removing the superficial epithelium would destroy the eye.

The nurse is selecting sensory aids for a client with deficits in hearing and sight. Which aid would address both sensory​ deficits? A. Adequate room lighting with night lights B. ​Large-print reading material C. Flashing alarm clock with large numbers D. Amplified telephone

C A flashing alarm clock would be helpful for a client with a hearing​ deficit, and a clock with large numbers would be helpful for a client with a sight deficit. Adequate room lighting with night lights and​ large-print reading material help with a sight deficit but not a hearing​ deficit, and an amplified telephone helps with a hearing deficit but not a sight deficit.

Which degree of alcohol use has been implicated in the development of​ alcohol-related neuropathy? A. Short term and light B. Acute and toxic C. Chronic and heavy D. Intermittent and severe

C Alcoholic neuropathy is damage to the nerves that results from​ long-term excessive use of​ alcohol, and so chronic and heavy are the best terms to describe the alcohol use that cause this type of peripheral neuropathy. This type of alcohol use is not short​ term, light,​ intermittent, or acute.

A type of infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home is called​ a(n) A. etiologic infection. B. latent infection. C. ​healthcare-associated infection. D. ​hospital-associated infection.

C A​ healthcare-associated infection, not a​ hospital-associated infection, is an infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home. Nurses must be diligent about hand hygiene and other safety practices to prevent​ healthcare-associated infections. A latent infection is an infection that is present but not active. All infections are​ etiologic; they are produced by a specific organism.

What is characteristic of conductive hearing​ loss? A. For loss of hearing to primarily involve the upper frequencies B. For loss of hearing to primarily involve the middle frequencies C. For loss of hearing to be the same at all frequencies D. For loss of hearing to primarily involve the lower frequencies

C Conductive hearing loss involves an equal loss of hearing at all frequencies. If the level of sound is greater than the threshold for​ hearing, speech discrimination is good. Because of​ this, the patient with a conductive hearing loss benefits from amplification by a hearing aid. Sensorineural hearing loss typically affects the ability to hear​ high-frequency tones.

What is conductive hearing​ loss? A. Damage to the hair cells of the organ of Corti B. Degeneration of the hair cells of the cochlea C. Disruption of the transmission of sound from the external auditory meatus to the inner ear D. Decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli

C Conductive hearing loss is any disruption of the transmission of sound from the external auditory meatus to the inner ear. Sensorineural hearing loss is a decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli. Damage to the hair cells of the organ of Corti is a significant cause of sensorineural hearing deficit. Degeneration of the hair cells of the cochlea is involved in progressive sensorineural hearing loss with​ aging, called presbycusis.

A hospital has created a culture of safety by providing organizational support for safety initiatives and by training and encouraging healthcare employees in the area of safety. What other step is needed to promote safety for everyone in the healthcare​ environment? A. Keep a mindset for quality of safe practice B. Post signs related to safety on the walls C. Engage clients in their own safety D. Be a safety advocate for others

C Healthcare facilities should use a​ three-pronged approach to quality and safety for​ everyone, including organizational support for keeping safety a​ priority, encouraging employees to consistently choose to follow health safety rules and​ standards, and actively engaging clients in every aspect of their​ care, including safety. Keeping a mindset for quality of safe practice and posting signs related to safety relates to the organizational support for safety. Being a safety advocate for others is related to employees maintaining safety standards.

Which statement regarding risk factors for peripheral neuropathy is​ accurate? A. Extremely short people are at the highest level of risk for developing peripheral neuropathy. B. Height is a risk factor for men but not a proven risk factor for women. C. Risk for peripheral neuropathy is proportional to height for both men and woman. D. Height is a risk factor for women but not a proven risk factor for men.

C Height has been identified as a risk factor for the development of peripheral​ neuropathy, independent of gender or presence of diabetes mellitus. Men who are taller than 167 cm​ (5 ft 6​ in.) and women who are taller than 159 cm​ (5 ft 3​ in.) are at higher risk for developing peripheral neuropathy than individuals of shorter​ height, and they are at higher risk of amputation if they do develop peripheral neuropathy.

A client is diagnosed with a detached retina. Which is the priority nursing diagnosis for this​ client? A. Anxiety B. Acute Pain C. Risk for Injury D. Risk for Infection

C Immediate intervention is required for a client with a detached retina to prevent permanent injury and preserve vision.​ Thus, the priority nursing diagnosis for the client would be Risk for Injury. The client will most likely demonstrate anxiety with the loss of​ vision; however, preventing permanent retinal injury is the priority. Risk for infection would not be a priority until the retina is reattached. A detached retina is not typically accompanied by pain.

Which strategy for communication enhancement incorporates the use of​ shapes? A. Oral approach B. Sign language C. Cued speech D. Total communication

C Of the strategies​ listed, only cued speech incorporates the use of shapes.​ Specifically, cued speech accompanies oral speech with hand shapes that represent groups of consonant sounds. Both sign language and total communication use​ signs, not shapes. An oral approach involves only spoken communication and avoids the use of formal signs.

The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of​ infection? A. Wear sterile gloves for client care. B. Place contaminated linens in a paper bag. C. Use personal protective equipment​ (PPE). D. Cover​ one's cough by placing the mouth in the hand.

C PPE, according to Occupational Safety and Health Administration​ (OSHA) standards, has to be used whenever the situation dictates and is a nursing measure to break a link in the chain of infection. Placing linens in a paper bag would allow germs to come out through the​ bag, and the linen would act as a​ fomite, thus allowing the chain to continue. Covering​ one's mouth when coughing prevents airborne droplets from escaping into the air for others to contract in the chain of infection.​ However, the cough should be covered in the​ elbow, not in the hand. Nonsterile gloves have to be worn when providing certain aspects of client care. The gloves should be changed between​ clients, and hands are to be washed.

A client has been diagnosed with cataracts of both eyes. The​ client's vision and activities of daily living have become severely impaired. What collaborative intervention does the nurse anticipate for this​ client? A. Two surgical procedures to remove both cataracts at the same time B. Eyedrops to treat the cataracts C. Two surgical​ procedures, separated by a few​ weeks, to remove the cataracts D. Corrective lenses for the cataracts

C Surgery is the only treatment for cataracts. The client will have one cataract​ removed, and​ then, in a few​ weeks, the other cataract will be removed. Cataracts cannot be treated with eyedrops or corrective lenses.

An older adult client tells the nurse that reading is easier when the material is held to the left or right. What should the nurse suspect this client is​ experiencing? A. Cataract B. Exudative macular degeneration C. Nonexudative macular degeneration D. Detached retina

C Symptoms of​ age-related macular degeneration usually develop gradually and include needing more light to​ read, blurriness of​ print, or a blurred or blind spot in the central vision. The macular degeneration is likely nonexudative​ (dry) because that is the more common kind and it develops before the exudative​ (wet) type. Cloudy vision is seen with cataracts. When the retina​ detaches, the client experiences​ floaters, or​ spots, and lines or flashes of light in the visual field.

The nurse is preparing discharge instructions for a client with​ age-related macular degeneration​ (AMD) and type 1 diabetes mellitus. What should the nurse include in this​ client's teaching​ plan? A. Information on the need to have routine eye examinations every 5 years B. Information on​ assisted-living facilities C. Referral to home care to ensure safety with administering insulin and AMD medications at home D. Information on Stargardt disease

C The client has macular degeneration and type 1​ diabetes, which means the client needs insulin at least once per day. The nurse should refer the client for home care to ensure that the client can safely provide insulin at home as well as assist with other medications the client might need for management of AMD. The client may or may not need to move to an​ assisted-living facility. Stargardt disease is the most common type of juvenile macular degeneration and not likely relevant to this client. Routine eye examinations for this client should be done every 2 years.

An older adult client with bilateral​ cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which is the priority nursing diagnosis for this​ client? A. Ineffective Coping B. Decisional​ Conflict: Cataract removal C. Risk for Ineffective Health Maintenance D. Disturbed Body Image

C The client has​ arthritis, which is a chronic condition and may interfere with the​ client's ability to manage​ self-care and postoperative care after cataract removal. Risk for Ineffective Health Maintenance is the diagnosis with the highest priority for the client at this time. There is no evidence to suggest the client is not coping or is experiencing decisional conflict regarding the removal of the cataracts. The client might have a disturbed body​ image; however, postoperative care is the highest priority at this time.

Which client should the nurse identify as having the greatest risk for hearing​ loss? A. Teacher who works at a large high school B. Adolescent who occasionally listens to loud music on headphones C. Construction worker who typically works in urban centers D. Lawyer who enjoys snowmobiling once a year

C The construction worker is likely to have the greatest risk for hearing loss because the​ client's occupation and typical work environment probably involve sustained exposure to very loud noises. An adolescent who occasionally listens to loud music on headphones is also at risk for hearing​ loss, but the exposure to loud sounds is only occasional. The teacher working at a large high school works in a noisy environment but is probably not typically exposed to sounds louder than the human voice. Snowmobiles can be loud enough to present a risk for hearing​ loss, but the​ lawyer's exposure to them is only once a year.

The nurse is planning care for a client scheduled for cataract surgery. Which intervention should the nurse include in the plan of care to help provide a safe environment for the client following​ surgery? A. Making the​ client's close family aware of the​ self-care instructions the client has received B. Ensuring the​ client's employer does not expect the client to return to standard duties until clearance for such activities by the healthcare provider C. Ensuring fall hazards are removed from the​ client's home and additional lighting is provided D. Educating the client about what​ self-care activities are necessary following surgery

C The removal of fall hazards from the​ client's home and provision of additional lighting best demonstrates providing a safe environment for the client following surgery.​ It's important for the client to understand what​ self-care activities are​ necessary, and​ it's good that the​ client's close family members are aware of the​ self-care instructions the client has received and that the​ client's employer​ doesn't expect an immediate return to standard​ duties, but these​ don't relate directly to providing a safe environment.

What are the two components of the sensory​ process? A. Visual and auditory B. Kinesthesia and stereognosis C. Reception and perception D. Stimulus and receptor

C The sensory process involves two​ components: reception and perception. Sensory reception is the process of receiving stimuli or data. Sensory perception involves the conscious organization and translation of the data or stimuli into meaningful information. Stimuli and receptors are aspects of how sensory information is received and perceived. Kinesthesia is awareness of the position and movement of body​ parts, and stereognosis is the ability to perceive and understand an object through touch. Visual and auditory stimuli are parts of how the body senses the external world.

A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. Which of the following should the nurse plan on teaching the client how to​ do? A. Understand the actions and drug interactions of aminoglycosides. B. Use total communication. C. ​Self-monitor for hearing loss. D. Understand cued speech.

C Tobramycin, an aminoglycoside​ antibiotic, is used in the treatment of advanced bacterial infections and for the treatment of tuberculosis. A potential serious adverse effect of this class of medication is​ ototoxicity, affecting the​ client's hearing. The nurse should plan on teaching the client how to​ self-monitor for hearing loss. Total communication and cued speech are approaches to enhancing communication with clients who have a hearing deficit. It is not important for the client to understand the actions and drug interactions of the group of drugs to which tobramycin belongs.

Which of the following clients most likely will require assistance with properly taking medications for macular​ degeneration? A. ​52-year-old client, gastroesophageal reflux disease​ (GERD), hypertension B. ​72-year-old client, no​ dementia, no​ arthritis, hypertension C. ​67-year-old client,​ dementia, arthritis, no hypertension D. ​47-year-old client, no comorbidities

C Two common conditions in older adults that may affect treatment of macular degeneration are tremors and cognitive decline. Hand tremors may make it difficult for the older adult to adequately apply​ eyedrops, and cognitive decline may cause older adults to forget to take their medications.​ Therefore, older adults with these conditions may need a family member or friend who can help them remember to take their medications and potentially apply eyedrops for them. The client with dementia and​ arthritis, although not the oldest of these​ clients, has conditions that are most likely to make taking medications properly difficult.

Several nurses are discussing the Joint​ Commission's 2016 National Patient Safety Goals during a staff meeting. Which element of performance should the nurses implement to meet the goal of identifying clients​ correctly? A. Marking the intended surgical site on the client B. Labeling all medications with the​ client's name C. Consistently using two methods to identify the client D. Asking the​ client's name before conducting assessments

C Two elements of performance that accompany the goal to identify clients correctly include consistently using two methods to identify the client and ensuring that clients receiving blood transfusions are correctly identified prior to transfusion. Labeling medications with the medication information helps prevent medication​ errors, and marking the intended surgical site on the client helps prevent surgical errors. Asking the​ client's name before conducting assessments is not associated with a National Patient Safety Goal.

What is​ vertigo? A. An infection of the vestibular nerve B. Impaired olfaction C. A feeling of rotation or imbalance D. Involuntary rapid eye movements

C Vertigo is a feeling of rotation or imbalance. Nystagmus is involuntary rapid eye movements. Vestibular neuritis is an infection of the vestibular nerve that is a common cause of vertigo. Impaired​ olfaction, or impaired sense of​ smell, has nothing to do with vertigo

The nurse is planning care for an older adult client diagnosed with​ age-related macular degeneration​ (AMD) that is nonexudative. Which therapies should the nurse anticipate for this​ client? Select all that apply. A. Eyedrops B. Laser surgery C. Zinc D. Eye patches E. Antioxidants

C E High-dose antioxidants and zinc are the treatments of choice for​ early-to-intermediate dry AMD. Laser surgery is used to treat wet macular degeneration. Eyedrops and eye patches may be used after laser surgery but are not part of the initial treatment for the disorder.

A nurse working in the emergency department is caring for a client with an eye injury. The client describes spots in the field of vision. Based on this​ finding, which of the following is the​ nurse's priority​ concern? A. The possibility that the​ client's conjunctiva will become red and edematous B. The possibility that the client will immediately lose all vision C. The possibility that the client will begin to experience intense eye pain D. The possibility that the client will experience a progressive deterioration of vision

D "Floaters," or irregular lines or spots in the​ client's field of​ vision, are a symptom of retinal detachment. With retinal​ detachment, the client is at risk for progressive deterioration of vision. Complete vision loss would be more likely with penetrating or perforating trauma or burn injuries. A​ red, edematous conjunctiva is more likely with burns. Intense eye pain is more likely with corneal abrasions or a foreign body being on the conjunctiva.

What characterizes individuals with​ achromatopsia? A. They perceive only the primary colors of​ red, blue, and yellow. B. They perceive only the secondary colors of​ purple, orange, and green. C. They perceive some colors as indistinguishable from other colors. D. They perceive only shades of gray and no colors.

D Achromatopsia is a rare form of color blindness in which the individual cannot distinguish any color at all and sees only shades of gray. The most common variant of color blindness is the inability to distinguish between red and green. Less common is the inability to distinguish between blue and yellow. Many people with the​ blue-yellow variant also have problems distinguishing between green and red.

The nurse is providing teaching to a client related to maintaining healthy vision. Which of the following should the nurse identify as a modifiable risk factor for macular​ degeneration? A. 62 years of age B. Family history of AMD C. Caucasian ancestry D. Smoking 1 pack of cigarettes per day

D Although aging is the most significant risk factor for the development of macular​ degeneration, and being Caucasian and having a family history of AMD are also risk​ factors, of the options​ listed, only smoking is​ modifiable, meaning that it is a risk factor the client can control.

The nurse is planning care for a client with glaucoma who is experiencing anxiety as a result of the diagnosis. Which intervention should the nurse select to address this​ need? A. Refer the client to a counseling psychologist. B. Turn off the lights when leaving the​ client's room. C. Assure the client there is nothing to be afraid of. D. Support the​ client's use of coping mechanisms.

D Anxiety is a common response to a new diagnosis of glaucoma.​ Here, the most appropriate intervention would be for the nurse to support the​ client's use of coping mechanisms. Although referral to a psychologist may be necessary at some​ point, it typically is not an initial course of action. Assuring the client there is nothing to be afraid of minimizes the​ client's concerns and is not appropriate. Turning off the lights is not an intervention that will lessen the​ client's anxiety.

The nurse is caring for a client with a corneal abrasion. Which collaborative intervention should the nurse anticipate being included in the​ client's care? A. Surgery B. Flushing the eye with normal saline C. Bedrest and an eye shield D. Applying antibiotic ointment and an eye shield

D Applying antibiotic ointment would be indicated in the care of the client with a corneal abrasion. An eye shield such as an eye patch is further indicated because of the​ client's likelihood of rubbing the eye. Flushing the eye with normal saline is indicated for a burn injury to the eye. Surgery is indicated for penetrating injuries to the eye but is usually not necessary for corneal abrasion. Bedrest with an eye shield would be indicated for the care of the client with a blunt trauma to the eye.

Which statement about cataract surgery is​ correct? A. Cataract surgery may only be done on an inpatient basis with general anesthesia. B. Cataract surgery is not recommended except in cases of opacification of the remaining posterior capsule. C. Cataract surgery is typically bilateral and can be performed in a single day. D. Cataract surgery should be quick but may have to take place in stages.

D Cataract surgery should be quick because it typically is done on an outpatient basis with only local anesthesia. If the patient presents with bilateral​ cataracts, however, surgery is typically performed on only one eye at a​ time, with an interval of days to several weeks before surgery is performed on the second eye. Cataract surgery is not typically done on an inpatient basis and does not usually involve general anesthesia. Opacification of the remaining posterior capsule is a secondary​ cataract, which may form following cataract surgery and also should be removed. If a client has bilateral​ cataracts, the surgery to remove them would typically be performed on different days.

Which diagnostic technique is used to confirm the location and extent of​ cataracts? A. Visually inspecting the optic fundus using an ophthalmoscope B. Revealing a dark area instead of the red reflex through ophthalmoscopy C. Using tonometry to indirectly measure intraocular pressure D. Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract

D Cataracts are diagnosed on the basis of the​ patient's history and eye examination. The Snellen and Rosenbaum charts are used. A dilated eye exam with either an ophthalmoscope or​ slit-lamp examination provides a magnified view of the structures of the eye. Ophthalmoscope examination confirms the diagnosis by identifying the location and extent of a cataract. Revealing a dark area is something that would happen only as the cataract matures. Visually inspecting the optic fundus and using tonometry to measure intraocular pressure are diagnostic tests for glaucoma.

The nurse is providing client teaching on​ Guillain-Barré syndrome. Which explanation for a​ client's false perception that socks are being worn is​ accurate? A. Tactile hallucinations are part of this​ disorder, so the client is hallucinating that socks are present. B. The medications used to treat this disorder cause the client to feel as if socks are being worn. C. Confusion is a part of this​ disorder, so the client is simply confused as to whether socks are being worn. D. This disorder causes a change in sensation that makes the client feel as if socks are being worn.

D Changes in sensation related to​ Guillain-Barré syndrome frequently cause a​ "stocking-glove" pattern- in which clients feel as if stockings and gloves are being worn when they are not- as well as pain in the​ hands, feet, and legs. Tactile hallucinations and confusion are not part of the disorder. Medications are not causing the client to feel as if socks are being worn.

Which​ client's clinical manifestations are most consistent with​ Guillain-Barré syndrome? A. A​ 23-year-old client with peripheral neuropathy has poor glycemic control. B. A​ 13-year-old client feels weakness in the​ feet, ankles, and legs. C. A​ 55-year-old client experiences a lack of hand strength. D. A​ 5-year-old client feels leg pain and wants to be carried.

D Children younger than 6 years old with​ Guillain-Barré syndrome may present with a refusal to walk and pain in the legs. The​ 13-year-old client's feeling of weakness in the​ feet, ankles, and legs is likely an early manifestation of​ Charcot-Marie-Tooth syndrome, whereas the​ 55-year-old client's lack of hand strength is likely due to more advanced CMT syndrome. The​ 23-year-old client with poor glycemic control is likely due to​ diabetes, which is probably the cause of the​ client's peripheral neuropathy.

Foreign objects commonly cause what type of injuries among migrant farm​ workers? A. Blunt trauma B. Abrasions C. Burns D. Penetrating trauma

D Eye injuries among migrant farm workers are underreported. These individuals are exposed to a variety of risks such as​ chemicals, machinery,​ tools, and airborne soil and particulates. In one​ study, most reported eye injuries among migrant farm workers were penetrating wounds or open​ wounds, typically caused by foreign objects. An abrasion might not be an open​ wound, blunt trauma does not break the​ skin, and burns are not typically caused by foreign objects.

A nurse is working with several clients who are experiencing hearing loss. Of these​ clients, which is the best candidate for a cochlear​ implant? A. A client with a tumor of the middle ear B. A client with a perforated tympanic membrane C. A client with an obstruction of the external ear canal D. A client with sensorineural hearing loss from​ long-term exposure to loud noise

D For the client with a sensorineural hearing​ loss, a cochlear implant may be the only hope for restoring sound perception. Clients with a perforated tympanic​ membrane, an obstruction of the external ear​ canal, or a tumor of the middle ear all have problems that lead to conductive hearing​ loss, which would not be treated with a cochlear implant.

A nurse is providing teaching to a young adult client who is occasionally exposed to loud explosions on the job site. Which statement on the part of the client indicates that he accurately understands the potential risk to his​ hearing? A. ​"Hearing loss from exposure to loud noises actually has a genetic​ component." B. ​"Hearing loss attributed to loud noises is normally​ reversible, especially in younger​ people." C. ​"If my hearing is damaged on the​ job, I can have surgery to fix​ it." D. ​"Damage to the ear from loud noises can cause permanent hearing​ loss."

D Hearing loss attributed to loud noises can be profound and is often​ permanent, regardless of a​ person's age. With sensorineural hearing​ loss, the only hope for restoring sound perception might be a cochlear​ implant; however, this surgery is not appropriate for all cases of sensorineural hearing​ loss, and even if a client is an ideal​ candidate, implants​ aren't always successful. Hearing loss from loud noises has no genetic component.

Which of the following statements regarding idiopathic neuropathy is​ true? A. Idiopathic neuropathy is caused by nutritional deficits. B. Idiopathic neuropathy is hereditary in nature. C. Idiopathic neuropathy is caused by disease or illness. D. Idiopathic neuropathy has no known cause.

D Idiopathic neuropathies are from an unknown cause and account for up to​ 30% of neuropathies. These neuropathies are not hereditary and not caused by any identifiable factor such as nutrition or illness.

A nurse is caring for several pediatric clients who are affected by cataracts. Of these​ clients, which is the most obvious candidate for surgical removal of the​ cataract? A. ​Six-month-old infant with difficulty noticing toys or faces B. ​Two-month-old infant who is asymptomatic C. ​Three-month-old infant with diminished reaction to bright light D. ​One-month-old infant with no reaction to bright light and failure to notice toys or faces

D If vision impairment is​ significant, the infant should undergo surgical removal of the cataract within the first 2 months of life. For children older than 2​ months, cataract surgery should be performed at the discretion of the healthcare provider. The asymptomatic​ 2-month-old infant is not displaying signs of significant vision​ impairment, but the​ 1-month-old infant is. The​ 3- and​ 6-month-old infants are showing signs of vision impairment but are both at an age at which surgery may only be performed if the healthcare providers decides it is necessary.

An older adult client with intermediate dry macular degeneration calls the nurse complaining that his vision is suddenly much more distorted and colors do not seem right. Which action by the nurse is​ priority? A. Ensure the​ client's safety by raising the bedrails. B. Talk with the client to assess for other hallucinations that might be occurring. C. Check the​ client's medications for side effects of vision changes. D. Contact the healthcare provider for an immediate ophthalmologic evaluation.

D Individuals with dry intermediate macular degeneration can progress to exudative macular degeneration. A sudden distortion in vision and impaired color vision are signs of exudative macular degeneration and require prompt evaluation and treatment.​ Thus, the nurse needs to contact the healthcare provider so that the client can be seen by an ophthalmologist. The client most likely is not experiencing a side effect of medications. Ensuring the​ client's safety is​ important; however, the nurse needs to do more than raising the bedrails. The client is not​ hallucinating, although hallucinations are a sign of exudative macular degeneration as well.

Which best describes​ photophobia? A. Reactive to light B. Need for light C. Fear of light D. Aversion to light

D Photophobia is a sensitivity to light that clients with​ angle-closure glaucoma may sometimes​ experience, so aversion to light is closest to describing photophobia. It is not necessarily​ fear; phobia can be fear or aversion. There are many different types of reactivity to​ light, but photophobia is specifically a negative reaction. Photophobia typically involves the avoidance of​ light, not the need for it.

The nurse is planning a teaching seminar for parents of​ school-age children that focuses on eye safety. What should the nurse include in this educational​ session? A. Supervise young children when lighting fireworks. B. Sunglasses need only be worn during the summer months. C. All children should wear goggles when playing outdoors at all times. D. Keep sharp objects out of the reach of young children.

D Scissors, knives, and other sharp objects should be kept out of the reach of young children. Parents should not permit​ preschool-age children to handle or light​ fireworks, even with supervision. Eye protection should be worn when participating in sports that lead to eye​ injury, such as baseball or​ tennis; it is not necessary at all times. Sunglasses should be worn whenever a child is exposed to bright light​ outdoors, regardless of the season.

The nurse suspects that an older adult client has a hearing​ disorder; however, the client denies not being able to​ hear, and the family thinks the client is just becoming more absent minded with age. Which initial action by the nurse to assess the​ client's hearing is​ appropriate? A. Confront the client with the suspicion. B. Schedule a Weber and Rinne test. C. Use an otoscope to visualize the inner ear. D. Observe the​ client's interaction with family.

D The most telling of these options would be to observe the​ client's interactions with family. The nurse should assess for frequent requests to​ repeat, inattention to​ conversation, turning one ear to the​ conversation, and lip reading. The Weber and Rinne test and use of an otoscope may be a part of an assessment but will not yield the immediate information that simple observation would. The client has already denied having a hearing​ problem, so confronting the client with the​ nurse's suspicion will probably only alienate the client from the nurse.

After being diagnosed with​ cataracts, a client believes the right eye has a cataract but not the left​ eye, as there are no vision changes with the left eye. Which response by the nurse is​ accurate? A. ​"Surgery is still necessary for both​ eyes." B. ​"The changes being confined to one eye indicate a less severe​ cataract." C. ​"Only your doctor can tell if you have a cataract in your left​ eye." D. ​"Cataracts develop at different​ rates, so one eye may be more affected than the​ other."

D The nurse should respond that cataracts tend to occur in both eyes and develop at different​ rates, and one cataract generally matures more rapidly than the other. The nurse should not tell the client that the healthcare provider is the only one who can tell if the client has a cataract in the left eye. The lack of vision changes in the left eye does not necessarily indicate the severity of the​ condition, and surgery might not be necessary for either eye.

Which statement is​ true? A. Construction workers have a reduced risk of eye injury because of the many protective measures they take. B. Eye injuries are relatively uncommon with advances in safety and risk prevention. C. Eye injuries almost always take place in the home. D. The pathophysiology of an eye injury depends on the nature of the injury.

D The pathophysiology of an eye injury depends on the nature of the injury. Eye injuries may take place in the​ home, but they may also occur in other settings such as recreational sports events and the​ workplace, and adults who are at greatest risk of eye injuries include​ contractors, woodworkers,​ welders, and​ electricians, all of which occupations are heavily involved in construction work. Eye injuries affect more than 2.5 million Americans every year. Each year​ 50,000 people will permanently lose all or part of their vision as a result of injury.

The nurse is teaching a child care class for mothers of young children. What should the nurse teach as being the most common mode of transmission of infectious​ disease? A. Children who are sitting together eating meals B. Children who are playing board games C. Children who are playing with the same toy D. Children who​ don't wash their hands after using the bathroom

D The​ fecal-oral and respiratory routes are the most common sources of transmission in children. Microorganisms might be left on toys that children​ share, but this is not the most common mode of transmission of infectious diseases. Playing with board games will not transmit infectious disease. Eating together will not transmit infectious disease. Poor hand hygiene is a common source of transmission.

Which client should the nurse anticipate will have the greatest psychosocial​ needs? A. A client in isolation B. A client taking antibiotics C. A client under droplet precautions D. A client under standard precautions

A Clients requiring isolation precautions can develop psychosocial problems related to their separation from other​ people, including sensory deprivation and decreased​ self-esteem. The nurse will need to provide additional care for these clients to promote their psychosocial health. Clients taking antibiotics or under standard or droplet precautions may have psychosocial needs as​ well, but they will not be as severe as those of the client in isolation.

A pregnant client tested positive for group B streptococcus during her​ 36-week checkup. For which intervention should the nurse prepare the client in order to prevent transmission of infection to the​ neonate? A. Administration of antibiotics to the client during labor B. Administration of antibiotics to the neonate after birth C. Not breastfeeding the neonate during the first week after birth D. Delivery by cesarean section

A Group B streptococcus​ (GBS) can be transmitted to the newborn during delivery. Administration of antibiotics during labor and delivery can prevent this​ transmission, so the nurse should prepare the mother for this intervention. GBS is not transmitted to the neonate through​ breastfeeding, antibiotics are not given to the neonate after​ birth, and a positive GBS test does not require cesarean delivery.

A client is undergoing surgery to manage glaucoma. When providing postoperative teaching to this​ client, the nurse should emphasize that the client is now at increased risk for which form of​ cataracts? A. Secondary B. Congenital C. Traumatic D. Radiation

A A secondary cataract may form following surgery to correct another eye disorder. Congenital cataracts are hereditary and appear at birth or in early childhood. Traumatic cataracts result from injury to the​ eye, and radiation cataracts result from​ long-term exposure to radiation.

What class of drugs both decreases production of aqueous humor in the eye and increases drainage of aqueous humor from the uveoscleral​ pathway? A. Alpha2​-adrenergic agonists B. Cholinergic agonists C. ​Beta-adrenergic blockers D. Prostaglandin analogs

A Alpha2​-adrenergic agonists both decrease production of aqueous humor in the eye and increase drainage of aqueous humor from the uveoscleral pathway.​ Beta-adrenergic blockers decrease the production of aqueous humor in the​ eye, but they do not increase drainage of aqueous humor. Prostaglandin analogs increase drainage of aqueous humor from the uveoscleral​ pathway, but they do not decrease aqueous humor production. Cholinergic agonists increase drainage of aqueous humor through the trabecular meshwork via pupillary constriction.

A client recovering from a penetrating eye injury tells the nurse that some shadows and movement can be seen with the eye. Based on this​ data, what should the nurse do​ next? A. Compare this data to the initial assessment. B. Note a deterioration in vision. C. Note an improvement in vision D. Administer ultrasonography to assess the eye for a detached retina.

A An initial assessment provides valuable information about the effect of the injury on the​ patient's vision and a baseline for future comparisons. In this​ case, if the client had been unable to see through the injured eye and now is able to see shadows and​ movement, that would indicate an improvement in vision. Deterioration in vision would be indicated by a lack of​ sight, but there is no way to know whether the​ client's condition has improved or worsened without comparing it to the baseline. The​ client's ability to see shadows and movement does not indicate the need for​ ultrasonography, but basic diagnostic testing of the​ eye's acuity and pupil reactivity and size is warranted.

A novice nurse has accepted a position on a​ medical-surgical unit at a local university hospital. In order to provide safe care to​ clients, the nurse should plan to develop which​ competency? A. Functioning as a member of the healthcare team B. Promoting appropriate values that clients should adopt C. Creating a culture of trust within the hospital D. Reporting families for bringing food to the​ client's room

A New nurses should learn about the healthcare team members and determine whom to collaborate with in certain situations. Rather than reporting​ families, the nurse would work with families to help meet their needs if food is not allowed in the room. The nurse would respect the values of clients and not seek to impose any on the clients. Creating a culture of trust is a system change that is implemented by the administration.

When a nurse performs or observes nursing practices that are not​ safe, the nurse has a responsibility to report those actions. This principle ties the concept of safety to what other nursing​ concept? A. Accountability B. Assessment C. Advocacy D. Clinical Decision Making

A Nurses are accountable for their​ actions, so all unsafe nursing practices should be reported and addressed. This principle does not reflect​ advocacy, assessment, or clinical decision making.

The nurse is caring for a​ 3-year-old child who is in the hospital for the first time. The child appears frightened and is clinging to her parents. What action can the nurse take to help the child feel more secure if the child needs to stay at the hospital without her​ parents? A. Have the parents bring comfort items from home to leave with the child B. Stay with the child when the parents go home C. Make sure the child wears proper identification at all times D. Keep dangerous medications and equipment out of the​ child's reach

A To help a child feel more​ secure, the nurse can suggest that parents bring in a few comfort items the child is familiar​ with, such as​ photos, a favorite​ blanket, or a favorite toy. Having the nurse stay with the child at all times once the parents have left is not practical and could cause harm to other clients under the​ nurse's care. Although the nurse should keep dangerous medications and equipment out of the​ child's reach and make sure the child wears proper identification at all​ times, these actions will likely not help the child feel more secure.

Which action by a nurse would require immediate intervention by another healthcare team​ member? A. Recapping a needle while holding the cap. B. Disposing of a needle in the sharps container. C. Recapping a needle using the scoop method. D. Recapping a needle with the use of a hemostat.

A When working with used or contaminated​ sharps, nurses will employ extra precautions so as to avoid unnecessary injuries. Needles that have been used will be disposed of in an appropriate sharps container. If sharps do need to be​ recapped, this should be done with the use of another device​ (such as a​ hemostat), or with the scoop method. Nurses should never hold the cap in one hand while trying to guide the tip of the needle into the cap with the otherdashthis method substantially increases the risk of a​ sharp-related injury.

A client in the intensive care unit is combative and pulling at the endotracheal​ tube, which must remain in place. After exhausting all​ alternatives, the nurse applies soft restraints to protect the​ client's airway. Which action should the nurse take​ next? A. Document the application of restraints in the chart. B. Notify the primary healthcare provider. C. Reassess the need for the restraints in 8 hours. D. Notify the family of the need for restraints.

B Restraints can only be applied under the order of a physician. When there is an urgency to protect the client and​ others, restraints can be applied and then the physician should be notified immediately to write an order for the restraints. The nurse would notify the family if​ present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every​ 1-2 hours.

A nurse conducted a class on fall prevention for a group of older adult clients in the community. Which observation during a client home visit indicates that teaching on fall prevention was​ effective? A. Scatter rugs are placed in the kitchen. B. A shower seat was placed in the shower. C. All meat is placed in the freezer. D. The locks were changed on the doors.

B A shower seat in the shower can prevent falls. The client who installed the seat has understood the​ nurse's teaching. Changing the locks may promote safety if there have been frequent​ break-ins, but there is no evidence of that. Scatter rugs in any area of the home are a safety hazard. Placing meat in the freezer does not help prevent falls.

The staff nurses are discussing interventions to reduce the risk of infection for the client population. Which intervention is the most important to decrease client​ infection? A. Assess vital signs once daily. B. Practice appropriate hand hygiene. C. Wear a mask for all client care. D. Raise the temperature in the​ client's room.

B Hand hygiene is always the first and best way to stop the spread of​ microorganisms, which cause infections. Assessing vital signs is important but should be done more frequently than once daily. Raising the temperature in a​ client's room would contribute to the growth of microorganisms. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.

A client who is living independently but needs skilled nursing services may take advantage of what type of​ healthcare? A. Telehealth B. Home healthcare C. Assisted living D. ​Long-term care

B Home healthcare provides a variety of​ medical, therapeutic, and nonmedical​ services, such as wound​ care, dietary​ counseling, physical​ therapy, occupational​ therapy, skilled nursing​ services, and homemaker services. These services are available in private homes from healthcare professionals. Telehealth would not be adequate for providing skilled nursing services. Assisted living facilities do not typically include skilled nursing services. One aspect of​ long-term care is skilled nursing​ services, but the clients do not live independently.

The home health nurse is talking with the parents outside the bathroom door while their​ 1-year-old twins are playing in the tub. Which client statement would require further safety​ teaching? A. ​"I often bathe the children​ together." B. ​"Why don't we talk in the living​ room?" C. ​"I do not like to leave the children alone in the​ bathroom." D. ​"Let me get the children out of the tub so we can​ talk."

B Infants and toddlers are at risk for​ drowning, even in small amounts of water. The nurse would want to teach the parent that it is never appropriate to leave young children unsupervised in the tub. Taking the children out of the tub and not wanting to leave toddlers alone in the bathroom demonstrates an awareness of risk. There is no risk with bathing the children together.

An experienced nurse has accepted a new position in the mental health unit after working in the​ medical-surgical floor for the past 4 years. What training would be beneficial for the nurse to refresh before starting her new​ position? A. How to safely lift and move clients B. How to manage aggressive behaviors C. How to properly use respirators D. How to prevent needlestick injuries

B The nurse is exposed to a higher risk of injuries from assaults by clients or their families in a mental health unit compared to a​ medical-surgical unit.​ Therefore, the nurse may benefit from receiving training related to managing aggressive behaviors. Because of her experience on the​ medical-surgical unit, the nurse is already likely familiar with how to safely lift and move clients and how to prevent needlestick injuries. Knowing how to use a respirator is more important for an infectious disease​ unit, not a mental health unit.

The nurse is caring for a client with a​ self-reported latex allergy. Which strategy can the nurse use to ensure the safety of this​ client? A. Keep beta adrenergic agonists on hand B. Wash hands after taking gloves off C. Wear hypoallergenic gloves D. Wear gloves with powder

B The nurse should wear​ latex-free gloves that are hypoallergenic and powderless. Not all hypoallergenic gloves are​ latex-free. Powder from the gloves can absorb the latex and be transferred to clients through touch or through the air.​ Therefore, it is important to wash hands after removing​ gloves, especially gloves with powder. Beta adrenergic agonists are used for the treatment of​ asthma, which may develop with chronic latex exposure in a sensitive​ individual, but it will not affect the early symptoms of latex allergy.

The nurse is caring for a​ 230-lb client who needs to be repositioned every 2 hours. While repositioning the​ client, the nurse injured a muscle in her back. To prevent the injury and ensure safety for both the nurse and​ client, what should the nurse have done differently in this​ situation? A. She should have repositioned the client only if the client requested it. B. She should have asked for help from another nurse. C. She should have questioned the physician about the need to reposition the client. D. She should have used proper lifting techniques.

B When moving or repositioning​ clients, especially larger​ clients, the nurse should always ask for help from another healthcare worker to prevent injury. Although using proper lifting techniques is​ important, they do not guarantee that injuries will not occur. In​ addition, there is no evidence that the nurse was not already using proper lifting techniques. The nurse should question physician orders if she is unclear about the reasoning for the​ order, but this is a standard best practice and would likely not require questioning. The nurse should reposition the client as​ ordered, not only when the client requests it.

The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of​ care? Select all that apply. A. Apply physical restraints if the client gets out of bed. B. Use side rails on client beds. C. Provide slippers for the client to wear while ambulating. D. Keep frequently used items within easy reach. E. Assess the​ client's vision and make sure he is using any prescribed eyewear.

B D E Assessing the​ client's vision and making sure he is using any prescribed eyewear is an appropriate action. Poor and blurry vision increases the​ client's risk of falling. Using side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention.​ Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if the client gets out of bed. The nurse should ensure that the client wears shoes with adequate traction while ambulating. Slippers may increase the risk for falls.

A hospital has had higher than average reports of client handling and movement injuries. What could the nurse advocate for that could most help reduce the number of client handling​ injuries? A. Encourage clients to lose weight B. Hire more nurses C. Purchase lifting devices D. Keep the clients restricted to bed

C Client handling and movement injuries are one of the leading causes of​ work-related injuries for nurses. Resources such as lifting​ devices, training, and lift teams can potentially reduce the number of occupational injuries of healthcare workers. Keeping the clients stationary would increase complications and slow the healing process. Encouraging clients to lose weight would not reduce injuries. Unless the hospital is​ understaffed, hiring more nurses would not help reduce injuries.​ Instead, nurses need to form lift teams to help reduce injuries.

The nurse is conducting a home risk assessment for a family with toddler and​ preschool-age children. Which should the nurse identify as the priority safety​ hazard? A. Child locks on the doors B. Safety plugs in electrical outlets C. Medications on the kitchen counter D. Lack of helmets next to bicycles

C The nurse would instruct the parents to keep medications out of the​ children's reach. Medication poisoning happens easily with young toddlers and​ preschool-age children who think the medication is candy. Safety plugs are appropriate for this age group. Child locks are appropriate to keep toddlers from wandering out to the street. A lack of a helmet next to a bike does not mean there are no helmets in the house. This finding would cause the nurse to ask more questions but is not considered a definite safety risk.

The nurse working in a healthcare setting is charged with inappropriate delegation after asking an unlicensed assistive personnel​ (UAP) to change the IV bag for a client. To which agency should this action be​ reported? A. Health Hazard Evaluation Program B. Occupational Health and Safety Administration C. Board of nursing D. Occupational Health Safety Network

C The state board of nursing has established procedures for reporting errors and violations made by licensed nurses and acts to investigate those reports. Complaints can include unsafe nursing​ practices, such as inappropriate delegation. The other agencies do not investigate nursing errors.

The nurse is assessing a​ 12-year-old male client. The client is within the normal range for​ height, weight, and body mass index​ (BMI) for his age. The client plans to play contact sports at school this year. He lives with his mother and attends​ after-school events when she is working late. What education should the nurse identify as a priority for this client to promote​ safety? A. The importance of maintaining a normal weight and participating in physical activity B. The importance of good hygiene practices and healthy diet C. The importance of using safety equipment when playing contact sports D. The importance of learning how to feel secure when he is at home alone

C The​ client's biggest safety risk is a risk of injury from contact sports. The nurse should encourage the client to use proper safety equipment to avoid injury. Promoting a sense of security is important for latchkey​ children, but this client does not appear to be home alone for extended periods based on participation in​ school, sports, and​ after-school activities. The client already has a normal weight and participates in physical​ activity, so education related to these topics is not as important as sports safety. There is no evidence that this client has poor hygiene or an unhealthy diet.

The home healthcare nurse is traveling to a​ client's home for the first time. What observation would suggest a safety hazard for the​ nurse? A. Client medications on the kitchen counter B. Neighbor walking a dog on a leash C. Porch steps that are broken and rotting D. Absence of street lights in the neighborhood

C Unhygienic or dangerous​ surroundings, such as broken and rotting porch​ steps, may pose a safety hazard for the nurse. Unrestrained and hostile animals may pose a safety​ threat, but a neighbor walking a dog on a leash is not a safety hazard for the nurse. Client medications on the kitchen counter may be a safety hazard if small children are present in the​ home, but this does not pose a safety hazard for the nurse. The nurse should only make home visits during daylight hours to maintain​ safety, so the absence of street lights in the neighborhood should not affect the nurse.

Reducing the risk of functional decline in older adults can help prevent which​ complication? A. Macular degeneration B. Hearing loss C. Hyperglycemia D. Pressure ulcers

D By reducing the risk of functional​ decline, nurses and independent older adults can help prevent complications such as pressure​ ulcers, delirium and​ depression, decreased​ mobility, loss of​ independence, and incontinence. Macular​ degeneration, hearing​ loss, and hyperglycemia are not complications that occur as a result of functional decline.

The nurse is conducting a class for a group of pregnant clients. Which topics should the nurse include when teaching this group about safety of the​ fetus? A. Pedestrian accidents B. Drowning C. Suffocation in the crib D. Alcohol consumption

D Alcohol consumption is a safety hazard for the​ fetus, and pregnant women should be educated about the importance of not drinking alcoholic beverages while pregnant. Suffocation in the crib is a safety hazard for both newborns and infants. Drowning is seen in toddlers and​ preschoolers, and pedestrian accidents are seen in the older adult.

The nurse is providing care to a pregnant client who has type 2 diabetes mellitus. The client has asked about how the medications she is taking will affect her fetus. How should the nurse​ respond? A. ​"The medications you are taking will not work as well when you are​ pregnant, so you should increase the dose of your​ medications." B. ​"The medications you are taking will not adversely affect your fetus. You should continue taking them as you did before your​ pregnancy." C. ​"The medications you are taking have a risk of causing fetal defects. You should stop taking your medications while you are​ pregnant." D. ​"If you have any concerns about how your medication will affect your​ fetus, you should talk to your primary care​ physician."

D Encouraging the client to change medication​ dosages, stop taking​ medications, or continue with the present treatment plan after a major change in health status is outside the nursing scope of practice. If the client has concerns about​ medications, she should talk to her primary care physician or other provider. Depending on the medication and the​ client's health​ status, the provider may recommend​ increasing, decreasing, or stopping treatment during​ pregnancy, or the client may continue the present treatment plan.​ However, the nurse can reinforce any teaching provided by the physician.

The nurse is providing care to a​ 12-year-old child with special needs and his caregiver. What strategies should the nurse help the caregiver teach the child to improve the​ child's safety? A. Teach the child to maintain airway with suctioning B. Teach the child to avoid secondhand smoke exposure C. Teach the child to schedule routine immunizations D. Teach the child how to use a telephone to call for help

D For children with special​ needs, the caregiver can work with the child to teach the child how to use a telephone to call for help when needed. The other actions are typically the responsibility of the caregiver or require the​ caregiver's help, including scheduling routine​ immunizations, keeping the child away from secondhand​ smoke, and suctioning the airway.

What nursing intervention is appropriate for a client with dry and cracked​ feet? A. Massage the​ client's feet daily B. Provide slippers for the client to wear at all times C. Soak the​ client's feet in water several times daily D. Apply lotion to the​ client's feet after bathing

D For clients with dry and cracked​ feet, the nurse should apply lotion to the​ client's feet after the​ client's bathing time. Providing slippers and massaging the​ client's feet will not heal dry and cracked feet. Soaking the​ client's feet in water without any added moisturizers may make the​ client's condition worse.

While reviewing safety precautions with the staff in a​ long-term care​ facility, which step should the nurse emphasize that helps to promote a safe environment for the​ clients? A. Turn off alarms to reduce noise. B. Keep clutter out of the hallway and inside the​ client's room. C. Provide dim lighting. D. Have the client wear shoes with rubber​ skid-resistant soles.

D Having the client wear shoes with rubber​ skid-resistant soles is the most appropriate intervention to decrease the risk of client​ falls, which will promote a safe environment. Dim lighting will increase the risk of client falls. Both the hallways and the​ clients' rooms should be clutter free. Noise should be kept to a​ minimum, but turning off alarms would endanger clients.

A nurse is assessing the hospital environment in order to decrease the risk for client falls. Which intervention should the nurse implement to decrease the risk of client​ falls? A. Lower side rails on client beds. B. Read label directions. C. Encourage the client to wear diapers. D. Clean the environment of clutter.

D Keeping the environment tidy and free of clutter will go a long way in preventing falls. Lowering side rails on client beds would increase the risk of falls. Reading label directions will prevent the wrong use of substances given to the client but would not directly prevent falls. Encouraging the client to wear diapers would increase functional​ decline, and it is not an appropriate strategy to help reduce falls.

A complaint about unsafe working conditions should be reported to which​ agency? A. American Nurses Association B. State board of nursing C. National Institute for Occupational Safety and Health D. Occupational Safety and Health Administration

D OSHA enforces the rights of workers to have a safe work environment.​ Therefore, complaints about unsafe work conditions should be filed with OSHA. NIOSH conducts research to provide advances in safety. State boards of nursing ensure that nurses are prepared and competent to provide safe nursing care. The American Nurses Association is a professional organization for nurses.

The nurse is caring for a​ 43-year-old client. What education should the nurse implement to best address the overall health promotion needs of someone in this age​ group? A. Tell the client to seek medical help for injuries B. Encourage the client to not drive while distracted C. Teach the client about ergonomic aids for computer use D. Teach the client about​ age-appropriate medical screenings

D The nurse can provide education in many areas related to disease​ prevention, including teaching about​ age-appropriate medical screenings. Teaching the client about ergonomic aids for computer​ use, telling the client to seek medical help for​ injuries, and encouraging the client to not drive while distracted are all methods to prevent​ injury, not disease.