MEDSRUG 40-43,63,64
A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis? Hot skin with a capillary refill of 1 to 2 seconds Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin Pain, diaphoresis, and erythema Jaundiced skin, weakness, and capillary refill of 3 seconds
Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin Explanation: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction. `
A client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, the client reports a new onset of pain at the surgical site. What is the nurse's best action? Administer pain medication as prescribed. Assess the surgical site and the affected extremity. Reassure the client that pain is a direct result of increased activity. Assess the client for signs and symptoms of systemic infection.
Assess the surgical site and the affected extremity. Explanation: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.
A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home? Maintain bed rest for 1 week. Lie on the stomach while sleeping. Avoid bending the head below the waist. Lift weights to increase muscle strength
Avoid bending the head below the waist. Explanation: The nurse should encourage the patient to avoid bending or stooping for an extended period. Keep activity light. Avoid lying on the side of the affected eye the night after surgery. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. Vitamin B12 Potassium Calcitonin Calcium Vitamin D
Calcium Vitamin D Explanation: A diet rich in calcium and vitamin D protects against skeletal demineralization. Intake of vitamin B12 and potassium does not directly influence the risk for osteoporosis. Calcitonin is not considered to be a dietary nutrient.
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? The malleus can be visualized during otoscopic examination. The tympanic membrane is pearly gray. Tenderness is reported by the client when the mastoid area is palpated. Clear, watery fluid is draining from the client's ear.
Clear, watery fluid is draining from the client's ear. Explanation: For the client experiencing acute head trauma, immediately report the presence of clear, watery drainage from the ear. The fluid is likely to be cerebrospinal fluid associated with skull fracture. The ability to visualize the malleus is a normal physical assessment finding. The tympanic membrane is normally pearly gray in color. Tenderness of the mastoid area usually indicates inflammation. This should be reported, but is not a finding indicating urgent intervention.
A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication? Subcutaneous emphysema Skin breakdown Compartment syndrome Disuse syndrome
Compartment syndrome Explanation: Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.
A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding? Fasciculations Clonus Effusion Crepitus
Crepitus Explanation: Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions. Fasciculations are involuntary twitching of muscle fiber groups. Clonus is the rhythmic contractions of a muscle. Effusion is the collection of excessive fluid within the capsule of a joint.
A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? Ossiculoplasty Insertion of a cochlear implant Stapedectomy Insertion of a ventilation or pressure-equalizing (PE) tube
Insertion of a ventilation or pressure-equalizing (PE) tube Explanation: If AOM recurs and there is no contraindication, a ventilating, or pressure-equalizing, tube may be inserted. The ventilating tube, which temporarily takes the place of the eustachian tube in equalizing pressure, is retained for 6 to 18 months. The ventilating tube is then extruded with normal skin migration of the tympanic membrane, with the hole healing in nearly every case. Ventilating tubes are used to treat recurrent episodes of AOM. Reference: • Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1892. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1892
A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? Keep the client's hips in abduction at all times. Keep hips flexed at no less than 90 degrees. Elevate the head of the bed to high Fowler's. Seat the client in a low chair as soon as possible.
Keep the client's hips in abduction at all times. Explanation: The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The client's hips should be higher than the knees; as such, high seat chairs should be used.
A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? Place slight additional tension on the traction cords. Release the weights and replace them immediately after positioning. Reposition the bed instead of repositioning the client. Maintain consistent traction tension while repositioning.
Maintain consistent traction tension while repositioning. Explanation: Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It would be inappropriate to add tension or release the weights. Moving the bed instead of the client is not feasible.
A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. The nurse should perform interventions to prevent what complication? Muscle clonus Muscle atrophy Rheumatoid arthritis Muscle fasciculations
Muscle atrophy Explanation: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results from immobility. Lack of exercise is a risk factor for rheumatoid arthritis. `
legally blind client is in pre-op area prior to an appendectomy. What steps does the nurse take to effectively communicate with this client ? Make direct eye contact with the client when communicating. Sit near the client to provide reassurance of the strange surroundings. Notify the client prior to touching the client. Inform the client that the nurse will be working nearby.
Notify the client prior to touching the client. Explanation: The nurse should announce upon arrival the bedside every time because many voices sound similar. The nurse should use the client's name initially so the client knows the nurse is communicating with the client directly. The nurse should speak before touching the client as not to startle the client. The nurse should notify the client when approaching and leaving the bedside each time. Orient the client to their surroundings using verbal descriptions and directions such as left, or right.
The RICE acronym is helpful for remembering treatment interventions for musculoskeletal injuries. Which of the following are components of the RICE acronym? Select all that apply. Rest Ice Compression Elevation Edema Corticosteroids
Rest Ice Compression Elevation Explanation: The acronym RICE stands for Rest, Ice, Compression, and Elevation. Edema and corticosteroids are not part of the RICE acronym.
A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client? Sit or stand in front of the client when speaking. Use exaggerated lip and mouth movements when talking. Stand in front of a light or window when speaking. Say the client's name loudly before starting to talk.
Sit or stand in front of the client when speaking. Explanation: Standing directly in front of a hearing-impaired client allows him or her to lip-read and see facial expressions that offer clues to what is being said. Using exaggerated lip and mouth movements can make lip-reading more difficult by distorting words. Backlighting can create glare, making it difficult for the client to lip-read. To get the attention of a hearing-impaired client, gently touch the client's shoulder or stand in front of the client.
A client presents to a clinic reporting of a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what? Staphylococcus aureus Proteus Pseudomonas Escherichia coli
Staphylococcus aureus Explanation: S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.
A client is recovering from a fractured hip. The nurse would suggest that the client increase intake of which of the following to facilitate calcium absorption from food and supplements? Amino acids Vitamin B6 Vitamin D Dairy products
Vitamin D Explanation: The nurse must advise a client recovering from a fractured hip to increase the intake of vitamin D, because vitamin D protects against bone loss and decreases the risk of recurring fracture by facilitating calcium absorption from food and supplements. Amino acids and vitamin B6, though important, do not facilitate the absorption of calcium. Dairy products also do not facilitate the absorption of calcium; however, the exception to this is vitamin D-fortified milk.
A bone biopsy has just been completed on a client with suspected bone metastases. The nurse should prioritize assessments for: dehiscence at the biopsy site. pain. hematoma formation. infection.
pain. Explanation: Bone biopsy can be painful and the nurse should prioritize relevant assessments. Dehiscence is not a possibility, since the incision is not linear. Signs and symptoms of infection would not be evident in the immediate recovery period and hematoma formation is not a common complication.
client diagnosed with a cataract comes into the clinic. What assessments should the nurse observe in this client? A burning sensation and the sensation of an object in the eye Blurred or cloudy visual image Inability to produce sufficient tears A swollen lacrimal caruncle
Blurred or cloudy visual image Explanation: When a cataract forms, the light is blocked from reaching the macula and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle. Reference:
A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action? Arrange for a STAT assessment of the client's serum calcium levels. Perform active range of motion exercises. Assess the client's joint function symmetrically. Contact the primary provider immediately.
Contact the primary provider immediately. Explanation: This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary. `
A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? Explain the location of items using clock cues. Explain that each of the items on the tray is clearly separated. Describe the location of items from the bottom of the plate to the top. Ask the client to describe the location of items before confirming their location.
Explain the location of items using clock cues. Explanation: The food tray's composition is likened to the face of a clock. It is unreasonable to expect the client to describe the location of items or to state that items are separated.
The client with a fractured femur is upset and agitated that skeletal traction will be necessary for 6 to 8 weeks. The client states, "How can I stay like this for weeks? I can't even move!" Based on these statements, the nurse would identify which of the following as the most appropriate nursing diagnosis? Ineffective Coping related to prolonged immobility Impaired Physical Mobility related to traction Deficient Diversional Activity related to prolonged hospitalization Activity Intolerance related to impaired mobility
Ineffective Coping related to prolonged immobility
A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication? Cellulitis Septic arthritis Sepsis Osteomyelitis
Osteomyelitis Explanation: Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic client because of the risk of osteomyelitis. Orthopedic clients do not have an exaggerated risk of cellulitis, sepsis, or septic arthritis when compared to other surgical clients.
The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care? Risk for disturbed sensory perception Risk for unilateral neglect Risk for falls Risk for ineffective health maintenance
Risk for falls Explanation: Vertigo is defined as the misperception or illusion of motion, either of the person or the surroundings. A client suffering from vertigo will be at an increased risk of falls. For most clients, this is likely to exceed the client's risk for neglect, ineffective health maintenance, or disturbed sensation.
A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? Perform chest physiotherapy once per shift and as needed. Teach the client to perform deep breathing and coughing exercises. Administer prophylactic antibiotics as prescribed. Administer nebulized bronchodilators and corticosteroids as prescribed.
Teach the client to perform deep breathing and coughing exercises. Explanation: To prevent these complications, the nurse should educate the client about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis and chest physiotherapy is unnecessary and implausible for a client in traction.
An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. What nursing intervention should be included in the client's subsequent care? Dressing changes should not be performed unless there are clear signs of infection. The surgical site can be soaked in warm bath water for up to 5 minutes. The surgical site should be cleansed with hydrogen peroxide once daily. The foot should be elevated in order to prevent edema.
The foot should be elevated in order to prevent edema. Explanation: Pain experienced by clients who undergo foot surgery is related to inflammation and edema. To control the anticipated edema, the foot should be elevated on several pillows when the client is sitting or lying. Regular dressing changes are performed and the wound should be kept dry. Hydrogen peroxide is not used to cleanse surgical wounds.
A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse? Write down the steps of the procedure for the patient to read before beginning the treatment. Change the dressing while the patient is reading the steps of the treatment because distraction decreases anxiety. Use nonverbal signals of agreement (head nodding), even if unsure, to instill confidence and trust. Minimize misunderstandings by completing the patient's sentences (e.g., fill-in-the-blanks) to decrease the patient's embarrassment.
Write down the steps of the procedure for the patient to read before beginning the treatment. Explanation: Written communication is an excellent resource and means of mutual understanding. Distraction is not appropriate because a hearing-impaired person needs the care provider's full attention. Do not pretend to understand or complete the person's sentences for them.
A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the client? The client should discuss this new remedy with her ophthalmologist promptly. The client should monitor her IOP closely for the next several weeks. The client should do further research on the herbal remedy. The client should report any adverse effects to her pharmacist.
he client should discuss this new remedy with her ophthalmologist promptly. Explanation: Clients should discuss any new treatments with an ophthalmologist; this should precede the client's own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not possible. `
The nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-administer these medications safely and effectively? Assess the client for any previous inability to self-manage medications. Ask the client to demonstrate the instillation of her medications. Determine whether the client can accurately describe the appropriate method of administering her medications. Assess the client's functional status.
Ask the client to demonstrate the instillation of her medications. Explanation: The client or the caregiver at home should be asked to demonstrate actual eye drop administration. This method of assessment is more accurate than asking the client to describe the process or determining earlier inabilities to self-administer medications. The client's functional status will not necessarily determine the ability to administer medication safely.
Which nursing intervention is appropriate for a client who plans to use a hearing aid? Describe the various types of hearing aids that are available Advise the client to purchase a hearing aid that is unnoticeable Advise the client to purchase from a company salesman Advise the client to purchase the hearing aid from a mail order catalog
Describe the various types of hearing aids that are available Explanation: The nurse should describe the various types of hearing aids that are available, some of which fit almost unnoticeably in the ear. The nurse should emphasize the importance of avoiding the purchase of a hearing aid from a mail order catalog or a company salesman. In addition, the nurse should encourage the client to be forthright and inform others about the hearing deficit, rather than trying to hide it.
A nurse is planning the care of a client with osteomyelitis that resulted from a diabetic foot ulcer. The client requires a transmetatarsal amputation. When planning the client's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? Ineffective Thermoregulation Risk-Prone Health Behavior Disturbed Body Image Deficient Diversion Activity
Disturbed Body Image Explanation: Amputations present a serious threat to any client's body image. None of the other listed diagnoses is specifically associated with amputation.
A nurse is caring for a client who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure chould the nurse implement to control the edema? Elevate the foot on several pillows. Apply warm compresses intermittently to the surgical area. Administer a loop diuretic as prescribed. Increase circulation through frequent ambulation.
Elevate the foot on several pillows. Explanation: To control the edema in the foot of a client who experienced foot surgery, the nurse will elevate the foot on several pillows when the client is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based on the guidelines provided by the surgeon. Reference:
A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? Allow the client to continue to scratch inside the cast with a pencil but encourage him to be cautious. Give the client a sterile tongue depressor to use for scratching instead of the pencil. Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe itching persists. Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.
Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe itching persists. Explanation: Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most clients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.
A nurse is caring for a patient who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.) Encouraging the patient to care for the residual limb Allowing the expression of grief Encourage the patient to have family and friends view the residual limb to decrease self-consciousness. Encouraging family and friends to refrain from visiting temporarily because this may increase the patient's embarrassment. Introducing the patient to local amputee support groups.
Encouraging the patient to care for the residual limb Allowing the expression of grief Introducing the patient to local amputee support groups. Explanation: The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grief process. The support from family and friends promotes the patient's acceptance of the loss. The nurse helps the patient deal with immediate needs and become oriented to realistic rehabilitation goals and future independent functioning. Mental health and support group referrals may be appropriate (McFarland et al., 2010). Amputation affects the patient's ability to provide adequate self-care. The patient is encouraged to be an active participant in self-care. `
The nurse in the ED is caring for a 4 year old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? External otitis is characterized by aural tenderness. External otitis is usually accompanied by a high fever. External otitis is usually related to an upper respiratory infection. External otitis can be prevented by using cotton-tipped applicators to clean the ear
External otitis is characterized by aural tenderness. Explanation: Clients with otitis externa usually exhibit pain, discharge from the external auditory canal, and aural tenderness. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external otitis so their use should be avoided.
A client with a fracture develops compartment syndrome that requires surgical intervention. The nurse would most likely prepare the client for which of the following? Bone graft Joint replacement Fasciotomy Amputation
Fasciotomy Explanation: Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.
Which of the following eye disorders is caused by an elevated intraocular pressure (IOP)? Glaucoma Cataracts Hyperopia Myopia
Glaucoma Explanation: In glaucoma, there is an abnormally high IOP. Cataracts occur when there is a clouding of the lens. Hyperopia is farsightedness. Myopia is nearsightedness.
A 6-year-old is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? Handwashing can prevent the spread of the disease to others. The importance of compliance with antibiotic therapy Signs and symptoms of complications, such as meningitis and septicemia The likely need for surgery to prevent scarring of the conjunctiva
Handwashing can prevent the spread of the disease to others. Explanation: The nurse must inform the parents and child that viral conjunctivitis is highly contagious and instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths, and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy. Clients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not associated with viral conjunctivitis.
A nurse is taking a health history on a new client who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the client's altered sensations? How does the strength in the affected extremity compare to the strength in the unaffected extremity? Does the color in the affected extremity match the color in the unaffected extremity? How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? Does the client have a family history of paresthesia or other forms of altered sensation?
How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? Explanation: Questions that the nurse should ask regarding altered sensations include "How does this feeling compare to sensation in the unaffected extremity?" Asking questions about strength and color is not relevant and a family history is unlikely.
A nurse is planning the care of a client who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions? Improving the client's level of function Helping the client come to terms with limitations Administering medications safely Improving the client's adherence to treatme
Improving the client's level of function Explanation: Improving function is the overarching goal after orthopedic surgery. Some clients may need to come to terms with limitations, but this is not true of every client. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional status.
The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? Increased warmth of the calf Decreased circumference of the calf Loss of sensation to the calf Pale-appearing calf
Increased warmth of the calf Explanation: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.
A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? Risk for Infection Risk for Ineffective Role Performance Risk for Perioperative Positioning Injury Risk for Powerlessness
Risk for Infection Explanation: The client has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated.
A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? Antioxidant supplements, vitamin C and E, beta-carotene, and selenium Eyeglasses or magnifying lenses Corticosteroid eye drops Surgical intervention
Surgical intervention Explanation: Surgery is the treatment option of choice when the client's functional and visual status is compromised. No nonsurgical (medications, eye drops, eyeglasses) treatment cures cataracts or prevents age-related cataracts. Studies recently have found no benefit from antioxidant supplements, vitamins C and E, beta-carotene, or selenium. Corticosteroid eye drops are prescribed for use after cataract surgery; however, they increase the risk for cataracts if used long-term or in high doses. Eyeglasses and magnification may improve vision in the client with early stages of cataracts, but have limitations for the client with impaired functioning.
A hospitalized client with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the client's room? That a commode is always available at the bedside That all furniture remains in the same position That visitors do not leave items on the bedside table That the client's slippers stay under the bed
That all furniture remains in the same position Explanation: All articles and furniture must remain in the same positions throughout the client's hospitalization. This will reduce the client's risks for falls. Visual impairment does not necessarily indicate a need for a commode. Keeping slippers under the bed and keeping the bedside table clear are also appropriate, but preventing falls by maintaining the room arrangement is a priority.
Which term refers to surgical repair of the tympanic membrane? Tympanotomy Myringotomy Ossiculoplasty Tympanoplasty
Tympanoplasty Explanation: Tympanoplasty may be necessary to repair a scarred eardrum. A tympanotomy, or myringotomy, are incisions into the tympanic membrane. An ossiculoplasty is a surgical reconstruction of the middle ear bones to restore hearing. Reference:
A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? Avascular necrosis of bone Compartment syndrome Fat embolism syndrome Complex regional pain syndrome
fat embolism syndrome Explanation: Fat embolism syndrome occurs most frequently in young adults and elderly clients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.
Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A middle-age adult who takes ibuprofen daily for rheumatoid arthritis An elderly client with an infected pressure ulcer in the sacral area A 17-year-old football player who had orthopedic surgery 6 weeks prior An infant diagnosed with jaundice
n elderly client with an infected pressure ulcer in the sacral area Explanation: Clients who are at high risk of osteomyelitis include those who are poorly nourished, elderly, and obese. The elderly client with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this client has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The client with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The client 6 weeks postsurgery is beyond the usual window of time for the development of a postoperative surgical wound infection.
A nurse is discussing conservative management of tendonitis with a client. What is the nurse's best recommendation? Weight reduction Use of oral opioid analgesics Intermittent application of ice and heat Passive range of motion exercises
ntermittent application of ice and heat Explanation: Conservative management of tendonitis includes rest of the extremity, intermittent ice and heat to the joint, and NSAIDs. Weight reduction may prevent future injuries but will not relieve existing tendonitis. Range-of-motion exercises may exacerbate pain. Opioids would not be considered a conservative treatment measure.
A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client should be kept in a prone position until otherwise ordered. What should the nurse do? Call the physician and ask for the order to be confirmed. Follow the order because this position will help keep the retinal repair intact. Instruct the client to maintain this position to prevent bleeding. Reposition the client after the first dressing change.
ollow the order because this position will help keep the retinal repair intact. Explanation: For pneumatic retinopexy, postoperative positioning of the client is critical because the injected bubble must float into a position overlying the area of detachment, providing consistent pressure to reattach the sensory retina. The client must maintain a prone position that would allow the gas bubble to act as a tamponade for the retinal break. Clients and family members should be made aware of these special needs beforehand so that the client can be made as comfortable as possible. It would be inappropriate to deviate from this order and there is no obvious need to confirm the order.
