NUR 220

A patient has undergone testing in which a clinician has scraped a sample from the patient's skin lesion and fixed the sample to a slide. This patient most likely has which of the following integumentary health problems?

A fungal infection

A male patient has reported to the nurse that he is experiencing sharp, intense pain when he blinks, and he claims that he has not previously experienced this problem. The nurse reports this finding to the primary care provider in the knowledge that the patient may have which of the following health problems?

An abrasion of the cornea

A middle-aged female patient is being treated with the Epley maneuver, which is designed to reposition the canalith by having the patient perform quick movements of the head. The nurse should recognize that this patient likely has a history of what health problem?

Benign paroxysmal positional vertigo (BPPV)

The nurse is preparing to discharge a patient home. During discharge teaching, the nurse realizes that the patient is not able to read the medication bottles and has not been taking her medications at home. How should the nurse intervene appropriately in this situation?

By asking the social worker to investigate community support agencies

A client is newly diagnosed with benign paroxysmal positional vertigo. Which is the priority nursing intervention?

Encourage bed rest.

A 44-year-old man has come to the clinic with an asthma exacerbation. He tells the nurse that his father and brother also suffer from asthma, as does his 15-year-old son. The nurse explains that this is an allergic response based on a genetic predisposition. The specific allergen initiated by this immunological mechanism is usually mediated by:

Immunoglobulin E

A woman who has experienced severe seasonal allergies in recent years has been referred for allergy skin testing. The nurse at the allergy clinic should be aware of the need to take precautions against the patient's risk of which of the following nursing diagnoses?

Impaired gas exchange

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if he experiences what?

New floater in vision

The nurse is conducting a physical assessment of a male patient who has been admitted to the hospital unit. The nursing documentation on the unit specifies an assessment of the patient's direct and consensual pupillary response. How should the nurse assess the patient's consensual pupillary response?

Shine a penlight in one of the patient's eyes while observing the response of the opposite eye

Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex?

They are localized to the area of exposure, usually the back of the hands.

A child goes to the school nurse and complains of not being able to hear her teacher. What test could the school nurse perform to make a general estimate of hearing loss?

Whisper test

A client comes to the clinic complaining of a rash on the arms, chest and upper thighs. Inspection reveals pink, raised lesions of varying sizes and shapes. The client reports that the lesions are "quite itchy and uncomfortable." The client's medication history is unremarkable. The nurse would document these lesions as:

urticaria

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?

Dyspnea, bronchospasm, and/or laryngeal edema.

A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?

Only use the nasal spray for 3 to 4 days once every 12 hours.

A 66-year-old man who originally sought care because of increasing pain in his great toe has subsequently been diagnosed with gout. In addition to pharmacological interventions, what dietary regimen should the nurse recommend to this patient?

High fluid intake and low protein intake

A patient has come to the office for her first eye examination and is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers mean. What is a correct response by the nurse?

"A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away."

A nurse is teaching a client about allergic rhinitis. What client statements indicate teaching has been effective? Select all that apply.

I should use my medication for allergy exacerbation only when my allergy is apparent." "I need to reduce my exposure to people that have upper respiratory infections." "I will remove as much carpet from my house as I can."

Otoscopic examination of a patient's internal ear reveals a significant amount of cerumen that makes complete visualization of the tympanic membrane difficult. Provided no contraindications exist, the nurse may remove the cerumen by:

Irrigating the patient's ear with warm water

A nurse is teaching a client about medications for glaucoma. What is the main marker of glaucoma control with medication?

Lowering intraocular pressure to target pressure

A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what?

Lymphocytes

Nursing students are reviewing the structure and function of the ears in preparation for class the next day. The students demonstrate understanding of the information when they describe which of the following as a middle ear structure?

Ossicles

The school nurse is approached by a teenage student. The student says that she learned in science class that the outer layer of the skin is dead cells. The student wants to know which of her cells is going to die so they can be covered with skin. What would be the nurse's best response?

"All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called keratin cells."

A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the patient in preparation for this test?

"Do you currently take sedatives, tranquilizers, or antihistamines on a regular basis?"

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

"My finger joints are oddly shaped."

As part of an admission assessment, the nurse is including questions that pertain to the patient's vision. Before conducting a physical assessment, the nurse is seeking to identify factors that have the potential to influence the patient's vision. Which of the following assessment questions most directly addresses these factors?

"What medications do you take?"

A middle-aged female patient has sought care because she has itchy, reddened areas on the backs of both of her hands and most of her fingers. On closer inspection, the nurse notes several cracks in the skin on these regions and observes that the patient's skin is exceptionally dry. What question should the nurse prioritize during this patient's assessment?

"When did you first begin having this problem?

A nurse in a long-term care facility has a longstanding relationship with a female resident whose osteoarthritis has become more severe in recent months. To facilitate the resident's continued engagement in activities and to promote her mobility, the nurse has begun implementing motivational interviewing (MI). The resident has stopped attending the quilting circle, stating, "I still enjoy quilting, but my knuckles are so painful lately." What response by the nurse best exemplifies MI?

"You say you'd like to keep quilting but it's painful. What ideas do you have for reducing your pain?"

When an impaled object is in the eye, which of the following steps should be taken to ensure that no further damage occurs? Select all that apply.

1. No attempt should be made to remove the object 2. Protect object from jarring 3. Use metal shield

A nurse is reviewing the medical records of several clients who have come to the clinic. Each of the clients wears corrective lenses. For the client with which corrected visual acuity would the nurse need to include additional devices and strategies to address low vision?

20/80

Which one of the following patients is most likely to be experiencing a health problem that may be a result of vestibular dysfunction?

A 78-year-old woman who requires open reduction and internal fixation of her left hip following a fall

You are the clinic nurse in an ophthalmic clinic. When assessing clients, which client has an abnormal intraocular pressure (IOP)?

A client with an IOP of 8 mm Hg

While performing perineal care for a female patient who has been recently admitted to the hospital, the nurse notes that the patient's pattern of pubic hair growth is more characteristic of a male's pattern of hair growth. The nurse should know that this could possibly be attributed to:

An endocrine disorder

Which factor aggravates the condition caused by acne vulgaris?

Friction

Which term refers to an incomplete antigen?

Hapten

The nurse is providing care for a young woman who has sought care because of signs and symptoms that are characteristic of psoriasis. When planning this woman's care, the nurse should be mindful of the fact that the etiology of the problem involves which of the following?

Immune dysfunction

During an intial assessment, the nurse notes a symptom of a mild case of bacterial conjunctivitis and documents in the electronic medical record that the client is displaying which of the following ?

Mucopurulent ocular discharge

A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?

Natural immunity

A middle-aged female patient has received a diagnosis of scleroderma with a chronic course and has been informed by her primary care provider that the disease has no cure. When considering the characteristic signs and symptoms of scleroderma, what nursing diagnosis should the nurse prioritize?

Risk for disturbed body image related to the integumentary effects of scleroderma

The nurse is planning the care of an 8-year-old boy who has been diagnosed with atopic dermatitis. In the boy's plan of nursing care, what nursing diagnosis should the nurse prioritize?

Risk for impaired skin integrity related to atopic dermatitis

The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful?

The belief is that it is an autoimmune disorder with an unknown trigger."

A boy has been brought to the clinic by his mother because of redness, swelling, and tenderness in the conjunctiva of his left eye. The nurse's inspection of the boy's eye also reveals the presence of purulent discharge in his left medial canthus. The nurse should anticipate that the boy will require what intervention?

Topical antibiotics

Prior to a clinical placement in an ambulatory ophthalmology clinic where cataract repairs and corneal transplants are performed, a nursing student is conducting a review of the anatomy and physiology of the eye. Which of the following descriptions is most accurate?

The muscles controlling the eye are innervated by several different cranial nerves.

The nurse is briefly reviewing a newly admitted patient's medical history prior to a shift change, and notes that the patient has low vision. The nurse should understand that this term denotes what?

The patient requires assistive devices to compensate for impaired visual acuity.

The nurse's assessment of an older adult patient who is postoperative day 1 following orthopedic surgery reveals scrotal edema. A review of the patient's recent documentation indicates that the patient is likely fluid overloaded. Why are areas such as the scrotum particularly susceptible to edema?

The vascularity and thin dermis of the scrotum make it prone to edema.

A nurse conducts the Weber test on a client. Which finding would the nurse interpret as normal?

can hear with both ears equally

A client who has been admitted for weakness and taking fluids poorly is unable to move well in the bed and requires assistance. What are this client's risk factors for developing pressure sores? Select all that apply.

dehydration immobility inactivity

The nurse is administering intravenous Vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs?

dyspnea, bronchospasm, and/or laryngeal edema

A client with multiple sclerosis is being seen by a neuroophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:

perimetry test

The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess? (Select all that apply.)

Decreased ventilation owing to lung scarring Dysphagia owing to hardening of the esophagus Dyspnea owing to fibrotic cardiac tissue

A patient has been treated for external otitis for the second time during the summer months. What education can be provided for the patient to reduce the risk of developing this problem? Select all that apply.

Do not clean the external canal with cotton-tipped applicators. Avoid getting the ear wet when swimming or showering. Use an antiseptic otic preparation after swimming, unless there is a history of tympanic membrane perforation.

Which test indicates the quantity of allergen necessary to evoke an allergic reaction?

Serum-specific IgE test

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer?

This test measures peripheral vision and detects gaps in the visual field.

A male patient in his 20s has presented to a free clinic with signs and symptoms that are highly suggestive of viral conjunctivitis. The nurse is aware of the relationship that can exist between sexually transmitted infections (STIs) and viral conjunctivitis. What assessment question is most likely to be clinically relevant?

Have you ever been diagnosed with herpes simplex virus (HSV)?" Correct response:

The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply.

Safe exercise Medication dosages and side effects Assistive devices

The parents of a child with contact dermatitis are asking questions about the reaction within the immune system. What description regarding contact dermatitis as a type IV hypersensitivity reaction is accurate?

a delayed-type hypersensitivity that is mediated by T cells