NUR2120 CH 45-50
The nurse is assisting the client in planning care during exacerbations of Ménière's disease. Which diet would the nurse identify as appropriate at this time? (Ch50) A) A high-protein diet B) A low-sodium diet C) A low-fat diet D) A calorie-controlled diet
B) A low-sodium diet Treatment for Ménière's disease is related to reducing fluid production in the inner ear, facilitating its drainage, and treating the symptoms that accompany the attack. A low-sodium and sodium-free diet lessens edema.
Students are reviewing information about orbital and ocular tumors. They demonstrate understanding of the material when they identify which of the following as the most common malginant tumor of the eyelid? (CH49) A) Basal cell carcinoma B) Squamous cell carcinoma C) Malignant melanoma D) Rhabdomyosarcoma
A) Basal cell carcinoma Basal cell carcinoma is the most common malignant tumor of the eyelid, followed by squamous cell carcinoma. Malignant melanoma is rare. Rhabdomyosarcoma is a malignant primary orbital tumor
The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis? (CH48) A) Identification of opacities on the lens B) Identification of white circle around the cornea C) Identification of yellowish aging spot on the retina D) Identification of redness of the sclera
A) Identification of opacitites on the lens The client states an increased glare and changes in color perception, which indicates a cataract. Identification of opacities on the lens confirms that diagnosis. A white circle around the cornea and a yellowish aging spot are also symptoms of aging but with different symptoms. Redness of the sclera indicates irritation.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms? (Ch47) A) impaired cerebral circulation B) cardiac disease C) diabetes insipidus D) hypertension
A) Impaired cerebral circulation TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, hypertension, or diabetes.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? (Ch47) A) Intracranial hemorrhage B) Ischemic stroke C) Age 18 years or older D) Systolic blood pressure less than or equal to 185 mm Hg
A) Intracranial hemorrhage ntracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
Which part of the retina is responsible for central vision? (CH48) A) Macula B) Optic disk C) Sclera D) Fundus
A) Macula The macula is the area of the retina responsible for central vision. The optic disk is the point of entrance of the optic nerve into the retina. The sclera helps maintain the shape of the eyeball and protects the intraocular contents from trauma. The fundus is the largest chamber of the eye and contains the vitreous humor.
The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack? (Ch50) A) Meclizine (Antivert) B) Furosemide (Lasix) C) Cortisporin otic solution D) Gentamicin (Garamycin) intravenously
A) Meclizine (Antivert) Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack (NIDCD, 2010).
Which of the following is considered a central nervous system (CNS) disorder? (CH46) A) Multiple sclerosis B) Guillain-Barré C) Myasthenia gravis D) Bell's palsy
A) Multiple sclerosis Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.
A nurse is obtaining a history from a new client with glaucoma. The client indicates having read about the diagnosis and understanding that this type of glaucoma is due to the degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the aqueous humor. The loss of absorption will lead to an increased resistance, and thus a chronic, painless buildup of pressure in the eye. Which type of glaucoma has the client described? (CH49) A) open angle B) angle closure C) congenital D) secondary
A) Open angle The client described open-angle glaucoma. This type of glaucoma develops painlessly, and visual changes occur slowly. As the IOP rises, it causes edema of the cornea, atrophy of nerve fibers in the peripheral areas of the retina, and degeneration of the optic nerve.
A client has developed diabetic retinopathy and is seeing the physician regularly to prevent further loss of sight. From where do the nerve cells of the retina extend? (CH48) A) optic nerve B) oculomotor nerve C) trochlear nerve D) trigeminal nerve
A) Optic nerve The nerve cells of the retina extend from the optic nerve.
Which reflects basic nursing measures in the care of the client with viral encephalitis? (CH46) A) Providing comfort measures B) Administering narcotic analgesics C) Administering amphotericin B D) Monitoring cardiac output
A) Providing comfort measures Providing comfort measures to reduce headache, including dimmed lights, limited noise, and analgesics, are the basic nursing measures in the care of the client with viral encephalitis. Narcotic analgesics may mask neurologic symptoms; therefore, they are used cautiously. Acyclovir therapy is commonly prescribed for viral encephalitis. Amphotericin B is used in the treatment of fungal encephalitis. Nursing management of the client with viral encephalitis includes monitoring of blood chemistry test results and urinary output to alert the nurse to the presence of renal complications related to acyclovir therapy.
Which phrase defines ossiculoplasty? (Ch50) A) Surgical reconstruction of the middle ear bones B) Surgical repair of the eardrums C) Incision into the tympanic membrane D) Incision into the eardrum
A) Surgical reconstruction of the middle ear bones Ossiculoplasty is performed to restore hearing. Surgical repair of the eardrum is termed tympanoplasty. Tympanotomy, or myringotomy, is the term used to refer to incision into the tympanic membrane.
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? (CH45) A) Temperature increase from 98.0°F to 99.6°F B) Urinary output increase from 40 to 55 mL/hr C) Heart rate decrease from 100 to 90 bpm D) Pulse oximetry decrease from 99% to 97% room air
A) Temperature increase from 98.0°F to 99.6°F Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.
The nurse is developing a plan of care for a patient who has stabilized after the emergency treatment of Guillain-Barré syndrome (GBS). What nursing intervention would receive priority for this patient? (Ch46) A) Using the incentive spirometer as prescribed B) the patient on bed rest C) Reorienting the patient to person, time, and place D) Limiting free water to 1 L per day
A) Using the incentive spirometer as prescribed Respiratory function can be maximized in GBS with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré does not affect cognitive function or level of consciousness. Fluid restriction is not indicated.
During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response? (CH48) A) cranial nerve VIII B) optic nerve C) cranial nerve VII D) facial nerve
A) cranial nerve VIII Nerve receptors for balance are found both in the vestibule and semicircular canals. They transmit information about motion through the vestibular nerve, which joins with the cochlear nerve to form the eighth cranial nerve (formally called the auditory or acoustic nerve).
A client is examined due to recent vision changes and is diagnosed with myopia. What is the cause of this client's vision change? (CH49) A) elongated eyeballs B) shortened eyeballs C) irregularly shaped corneas D) unequal curvatures in the cornea
A) Elongated eyeballs Myopia occurs in people with elongated eyeballs
A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition? (CH49) A) hyperopia B) emmetropia C) myopia D) astigmatism
A) hyperopia Hyperopia is farsightedness. People who are hyperopic see objects that are far away better than objects that are close.
The nurse is supervising a family member who instilling ear drops into the client's ear. Which of the following statements, made by the family member, would require further nursing instruction? (Ch50) A) "Turn your head to the side so I can put these drops in." B) "These drops are cold from being on the window sill." C) "Let me put this cotton ball in your ear because I put the drop in." D) "I squeeze the dropper to put a drop of medicine in the ear."
B) "These drops are cold from being on the window sill." When the family member states that the drops are cold, the nurse would encourage the family member to place the bottle in a warm bath or warm the bottle in their hands. Cold or hot liquids, instilled in the ear, may cause dizziness and potential for injury.
When caring for a patient who has had a hemorrhagic stroke, close monitoring of vital signs and neurological status is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke? (Ch47) A) Headache B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath
B) Alterations in LOC Alteration in LOC is the earliest sign of deterioration in a patient with a hemorrhagic stroke; these include mild drowsiness, slight slurring of speech, and sluggish papillary reaction.
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at (Ch46) A) preventing renal insufficiency. B) controlling seizures and increased intracranial pressure. C) maintaining hemodynamic stability and adequate cardiac output. D) preventing muscular atrophy.
B) controlling seizures and increased intracranial pressure. There is no specific medication for arbovirus encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.
A patient has been diagnosed with a loss of hearing related to damage of the end organ for hearing. What term is used to describe this condition? (CH50) A) Exostoses B) Otalgia C) Sensorineural hearing loss D) Presbycusis
C) Sensorineural hearing loss Exostoses are small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing or cranial nerve VIII. Presbycusis is the term used to refer to the progressive hearing loss associated with aging. Both middle and inner ear age-related changes result in hearing loss.
What is located in the cochlea of the inner ear? (CH48) A) Semicircular canals B) Labyrinth C) Vestibulocochlear nerve D) Organ of Corti
D) Organ of Corti The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea. The labyrinth is the name for the inner ear, and the semicircular canals and vestibulocochlear nerves are other components of the inner ear.
While conducting an assessment, a nurse notes that the client reports pain when moving the auricle. Which condition would the nurse most likely suspect? (Ch48) A) Acute external otitis B) Acute mastoiditis C) Impacted cerumen D) Ototoxic medication
A) Acute external otitis If the client reports pain upon manipulation of the auricle, the nurse should suspect the etiology of the pain is acute external otitis. Impaction of cerumen can cause otalgia (a sensation of fullness or pain in the ear), with or without a hearing loss. Tenderness on palpation in the area of the mastoid may indicate acute mastoiditis or inflammation of the posterior auricular node. Ototoxic medication commonly causes tinnitus.
A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse? (Ch48) A) Assess the tympanic membrane. B) Educate the client on the therapeutic effects of medications. C) Document the effectiveness of medications. D) Irrigate the ear.
A) Assess the tympanic membrane. A client diagnosed with otitis media who feels sudden relief of pain and/or pressure should be assessed for a tympanic membrane rupture. Educating the client on the therapeutic effects of medications is appropriate for newly diagnosed otitis media, but it does not address the sudden disappearance of pain and pressure. Because the medication usually takes 48 to 72 hours to be effective, documenting the medication as effective would be inappropriate. It is not necessary to irrigate an ear with otitis media.
A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography? (Ch48) A) BUN and creatinine B) AST and ALT C) Hemoglobin and hematocrit D) Platelet count
A) BUN and creatinine Angiography is done using fluorescein or indocyanine green as contrast agents. Fluorescein angiography is used to evaluate clinically significant macular edema, document macular capillary nonperfusion, and identify retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein. Prior to the angiography, the patient's blood urea nitrogen (BUN) and creatinine should be checked to ensure that the kidneys will excrete the contrast agent (Fischbach & Dunning, 2011).
A client has received a diagnosis of hyperopia and is wondering if there is a physical condition that has caused these vision changes. In explaining hyperopia, what does the nurse indicate is the cause of this client's vision changes? (CH49) A) eyeballs that are shorter than normal B) irregularly shaped corneas C) unequal curvatures in the cornea D) eyeballs that are longer than normal
A) Eyeballs are shorter than normal Hyperopia results when the eyeball is shorter than normal, causing the light rays to focus at a theoretical point behind the retina.
A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included? (CH48) A) eyelids B) cornea C) iris D) pupil
A) Eyelids The sclera does not attach to the eyelids. The sclera protects structures in the eye, and connects directly to the cornea, anterior chamber, iris, and pupil.
If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing (CH50) A) facial nerve paralysis. B) nystagmus. C) motor impairment. D) diplopia.
A) Facial nerve paralysis If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care? (CH45) A) Ineffective airway clearance related to altered LOC B) Risk of injury related to decreased LOC C) Deficient fluid volume related to inability to take fluids by mouth D) Risk for impaired skin integrity related to prolonged immobility
A) Ineffective airway clearance related to altered LOC The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
A patient is participating in aural rehabilitation. The nurse understands that this type of training emphasizes which of the following? (Ch50) A) Listening skills B) Social skills C) Occupational skills D) Functional skills
A) Listening skills Auditory training emphasizes listening skills, so the person who is hearing-impaired concentrates on the speaker.
A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? (CH45) A) Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. B) Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. C) Reassure the client that a headache is expected and will go away without treatment. D) Notify the physician; a headache is an early sign of worsening neurologic status.
B) Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? (Ch46) A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity
B) Confusion In the postictal state (after the seizure), the patient is often confused, hard to arouse, and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.
It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye? (CH48) A) 20/50 B) 20/100 C) 20/150 D) 20/200
D) 20/200 Legal blindness is a condition of impaired vision in which a person has best corrected visual acuity that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less (Prevent Blindness America, 2012).
The nurse on the medical-surgical floor is reviewing discharge instructions with a patient who has a history of glaucoma. Which classification of drugs on the patient's discharge instructions is used to treat the patient's glaucoma? (Ch49) A) Antiemetics B) Cholinergics C) Antibiotics D) Angiotensin-converting enzyme (ACE) inhibitors
B) Cholinergics Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle, thus causing miosis and opening the trabecular meshwork.
The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? (CH46) A) IV phenobarbital B) IV diazepam C) IV lidocaine D) Oral phenytoin
B) IV Diazepam Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.
A client with quadriplegia is in spinal shock. What finding should the nurse expect? (CH45) A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities
A) Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? (CH45) A) acute B) chronic C) subacute D) intracerebral
A) Acute Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.
A nurse is preparing a plan of care for a client with otitis externa. Based on the typical assessment findings, which of the following would the nurse most likely identify as the priority nursing diagnosis? (CH50) A) Acute pain related to inflammation B) Risk for infection related to drainage from the ear canal C) Disturbed sensory perception: auditory related to sensorineural hearing loss. D) Hyperthermia related to elevated temperature secondary to infection
A) Acute pain related to inflammation The client with otitis externa typically reports pain as well as aural tenderness, making the nursing diagnosis of acute pain the priority. A major component of therapy is relief of the pain and discomfort with analgesics and antibiotics and corticosteroid agents to soothe the inflamed tissues. Inflammation is present, which could lead to infection, but this would not be the priority. Typically, clients with otitis externa experience a conductive hearing loss. Fever may or may not be present.
The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform? (CH49) A) Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye B) Holds down the lower lid of the eye by applying pressure on the eyeball and the cheekbone C) Applies gentle pressure to the upper eyelid to keep the lid open while telling the client to gaze upward D) Applies firm pressure to the upper and lower eyelids at the outer edges to keep eyelids in approximatio
A) Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye Punctal occlusion is done by applying gentle pressure to the inner canthus of each eye for 1 to 2 minutes immediately after eye drops are instilled. The nurse does not apply pressure to the eyeball when administering medications. The lower eyelid is held down to expose the conjunctival sac. The other action described will not aid in the retention or absorption of medication.
A patient with significant and increasing sensorineural hearing loss has opted not to have surgery and has chosen instead to focus on aural rehabilitation with an emphasis on auditory training. What will be the primary focus of the patient's rehabilitation? (Ch50) A) Developing effective skills and strategies for listening B) Learning to use sign language effectively C) Developing coping techniques for dealing with a lack of communication D) Developing nonverbal communication techniques
A) Developing effective skills and strategies for listening Auditory training emphasizes listening skills, so the person who is hearing-impaired concentrates on the speaker. Speech reading (formerly known as lipreading) can help fill the gaps left by missed or misheard words. This particular form of training does not have a primary emphasis on coping techniques, nonverbal communication, or sign language.
A diabetic patient is scheduled for surgery for repair of a detached retina that was caused by proliferative retinopathy. The nurse prepared the patient for surgery, aware that the type of detachment is most likely classified as which of the following? (Ch49) A) Rhegmatogenous B) Traction C) Exudative D) Traction combined with rhegmatogenous
A) Rhegmatogenous Rhegmatogenous detachment is the most common form of retinal detachment. In this condition, a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the retinal pigment epithelium.
Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear? (CH49) A) Scleral buckle B) Pars plana vitrectomy C) Pneumatic retinopexy D) Phacoemulsification
A) Scleral buckle The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.
Which are accurate clinical manifestations of a retinal detachment? (CH49) A) Sudden onset of a greater number of floaters B) Cobwebs C) Bright flashing lights D) Pain
A) Sudden onset of a greater number of floaters Clients may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Clients with retinal detachment do not complain of pain.
After thorough diagnosis and screening, a 9-year-old boy has been scheduled for a cochlear implant. The nurse who will be contributing to this child's care should recognize that: (CH50) A) The boy's hearing deficit will be considered normal within 24 to 48 hours after surgery. B) A lengthy period of learning may be required before he can accurately interpret sounds. C) The boy will achieve hearing through bone conduction. D) The cochlear implant will provide a beneficial, but temporary, solution to the boy's hearing loss.
B) A lengthy period of learning may be required before he can accurately interpret sounds. Following a cochlear implant, several months may be needed to learn to interpret the sounds heard. Children and adults who lost their hearing before they learned to speak take much longer to acquire speech. The implant is not a temporary measure, however. It does not achieve hearing through bone conduction.
You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis? (Ch50) A) The client being distressed in the mornings B) A progressive, bilateral loss of hearing C) A red and swollen ear drum D) The client describing a history of having had a recent upper respiratory infection
B) A progressive, bilateral loss of hearing A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? (CH46) A) Assess client's reaction to new medication schedule. B) Administer medications at exact intervals ordered. C) Document medication given and dose. D) Give client plenty of fluids with medications.
B) Administer medications at exact intervals ordered. The nurse must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.
A 79-year-old man is being assessed for age-related macular degeneration (AMD) and will be taught strategies for self-assessing changes in visual acuity. This patient should be: (CH49) A) Provided with a Snellen chart and taught to use it correctly B) Given an Amsler grid and encouraged to use it several times a week C) Provided with a prescription for pilocarpine hydrochloride (Isopto Carpine) D) Encouraged to read books and magazines with a small font size
B) Given an Amsler grid and encouraged to use it several times a week Amsler grids are given to patients with AMD to use in their home to monitor for a sudden onset or distortion of vision. These may provide the earliest sign that macular degeneration is getting worse. Patients should be encouraged to use these grids and to look at them, one eye at a time, several times each week with glasses on. Pilocarpine is not used to treat AMD, and the Snellen chart is not normally used for self-assessment. There is no need to have the patient read materials with fine print.
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? (CH49) A) The patient requires eyeglasses or contact lenses to achieve clear vision. B) The patient requires assistive devices to compensate for impaired visual acuity. C) The patient has no light perception. D) The patient is unable to perform functional tasks due to decreased vision.
B) The patient requires assistive devices to compensate for impaired visual acuity. Low vision is a general term describing visual impairment that requires patients to use devices and strategies in addition to corrective lenses to perform visual tasks. It does not denote a lack of light perception, and the patient may or may not have significant functional deficits.
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education? (CH46) A) "I will take hot tub baths to decrease spasms." B) "I should participate in non-weight-bearing exercises." C) "I will stretch daily as directed by the physical therapist." D) "The exercises should be completed quickly to reduce fatigue."
C) "I will stretch daily as directed by the physical therapist." A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury. Clients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. Clients should not hurry through the exercise activity because it may increase muscle spasticity.
Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter? (CH46) A) Glutamate B) Acetylcholine C) Dopamine D) Serotonin
C) Dopamine The impaired balance and uncontrolled tremors of Parkinson's disease have been linked with low levels of dopamine. The other neurotransmitters have not been implicated in Parkinson's disease in this manner.
Postoperative nursing assessment for a patient who has had a mastoidectomy should include observing for facial paralysis, which might indicate damage to which cranial nerve? (Ch50) A) First B) Fourth C) Seventh D) Tenth
C) Seventh Injury to the seventh cranial nerve, also known as the facial nerve, is a complication of a mastoidectomy, although rare. Hearing loss of less than 30 dB is a more common complication.
A nurse who coordinates care in a long-term care facility is aware that almost 100% of the residents wear glasses and that many of them require surgical corrective procedures. Which of the following phenomena is considered to be an age-related change to vision? (Ch48) A) Beginning at around age 40, rods gradually replace cones. B) The optic nerve (CN II) becomes progressively demyelinated with age. C) The lens of the eye becomes more opaque with age. D) Intraocular pressure gradually increases, peaking around age 75.
C) The lens of the eye becomes more opaque with age. Increasing lens opacity is a normal, age-related change. Increased IOP and destruction of the optic nerve are considered pathophysiological processes in patients of any age. Rods do not replace cones as an individual ages.
Nursing management of the client with acute symptoms of benign paroxysmal positional vertigo includes (CH50) A) the Epley repositioning procedure. B) meclizine for 2 to 4 weeks. C) the Dix-Hallpike maneuver. D) bed rest.
D) Bed rest Bed rest is recommended for clients with acute symptoms. Canalith repositioning procedures may be used to resolve attacks of vertigo, and clients with acute vertigo may be medicated with meclizine for 1 to 2 weeks. The Epley procedure is not recommended for clients with acute vertigo. The Dix-Hallpike test is an assessment test used to evaluate for benign paroxysmal positional vertigo.
An elderly client with macular degeneration has received injections of angiogenesis inhibitors. Which assessment finding would indicate the condition is worsening? (CH49) A) Blurred vision B) Burning sensation of the eyes C) Loss of peripheral field vision D) Central vision impairment
D) Central vision impairment When the macula becomes irreparably damaged, central vision is lost and the client can only see images via peripheral field. Blurred vision is the initial symptom of the disease and does not signify worsening. Burning sensation is a common adverse reaction to the treatment injection
A registered nurse is orientating a group of nursing assistants at a large long-term care facility. A high percentage of residents have some form of hearing impairment, so the nurse is teaching appropriate communication strategies to the assistants. The nurse should teach these staff members to: (CH50) A) Use writing as the primary communication strategy with residents who are hearing impaired. B) Avoid interactions that cannot be communicated using gestures. C) Use simple concepts, simple vocabulary, and monosyllables whenever possible. D) Pause more frequently than usual when speaking to the individual.
D) Pause more frequently than usual when speaking to the individual. When speaking with people who are hearing impaired, it is important to speak slowly and distinctly, pausing more frequently than you would normally. This does not mean, however, that every concept that is discussed must be simple or that multisyllabic words cannot be used when appropriate. Writing can be a useful tool, but it is rarely the primary means of communication with an individual.
Which statement is accurate regarding refractive surgery? (CH49) A) Refractive surgery will alter the normal aging of the eye. B) Refractive surgery may be performed on all clients, even if they have underlying health conditions. C) Refractive surgery may be performed on clients with an abnormal corneal structure as long as they have a stable refractive error. D) Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea.
D) Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. Refractive surgery is an elective procedure and is considered a cosmetic procedure (to achieve clear vision without the aid of prosthetic devices). It is performed to reshape the cornea for the purpose of correcting all refractive errors. Refractive surgery will not alter the normal aging process of the eye. Clients with conditions that are likely to adversely affect corneal wound healing (corticosteroid use, immunosuppression, elevated intraocular pressure) are not good candidates for the procedure. The corneal structure must be normal and refractive error stable.
A severe fungal infection will soon necessitate the evisceration of a patient's left eye. The patient is currently receiving health education from the nurse about the future use of an ocular prosthesis. When providing this education, the nurse should emphasize what teaching point? (CH49) A) The fact that a lifetime course of topical antibiotics will be required B) The fact that the patient can be fitted with a prosthesis 8 to 10 months after the procedure C) The fact that a pressure dressing will be necessary for the first 24 to 36 hours after surgery D) The fact that a temporary conformer will be used in the immediate postsurgical period
D) The fact that a temporary conformer will be used in the immediate postsurgical period The temporary conformer is placed over the conjunctival closure after the implantation of an orbital implant. A conformer is placed after the enucleation or evisceration procedure to protect the suture line, maintain the fornices, prevent contracture of the socket in preparation for the ocular prosthesis, and promote the integrity of the eyelids. A pressure dressing is used for around 1 week, and antibiotics are not permanently needed. A prosthesis can usually be fitted a few weeks after surgery.
Blindness (CH49)
20/400 to no light perception
Aura (CH46)
Phase of migraine headache that lasts less than an hour.
Cushing's triad consists of: (CH45)
1. Bradycardia. 2. Bradypnea. 3. Hypertension.
Reasons for SCI (CH45)
1. motors vehicle accidents 2. violence related 3. falls 4. sports
Impaired vision (Ch49)
20/80 to 20/100
Which of the following medications decreases the production of aqueous humor? (CH49) A) Beta blockers B) Miotics C) Sympathomimetics D) Mydriatics
A) Beta blockers Beta blockers decrease the production of aqueous humor, with a resultant decrease in IOP. Miotics and sympathomimetics decrease the size of the pupil, facilitating the outflow of the aqueous humor, which decreases IOP. Mydriatics dilate the pupil.
A client is color blind. The nurse understands that this client has a problem with: (Ch49) A) rods. B) cones. C) lens. D) aqueous humor.
B) Cones Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: (CH45) A) Mild TBI. B) Moderate TBI. C) Severe TBI. D) Brain death.
C) Severe TBI. A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
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? (CH48) A) Ask the patient to follow the movement of pen from several feet away to near the tip of the patient's nose B) Ask the patient to look straight ahead while bringing a penlight in from the periphery of the patient's vision C) Shine a penlight in one of the patient's eyes while observing the response of the opposite eye D) Shine a penlight in the patient's eye while asking him to identify a common object with the other eye
C) Shine a penlight in one of the patient's eyes while observing the response of the opposite eye The pupillary response to light is determined by shining a bright light obliquely into each pupil. Pupils are assessed for direct reaction, in which the pupil tested with light constricts; and consensual reaction, in which the pupil of the opposite eye also constricts. Asking the patient to follow movement or identify an object are not techniques used to assess consensual pupillary response.
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? (CH46) A) The type of anticonvulsant prescribed to manage the epileptic condition B) Recent stress level C) Recent weight gain and loss D) Compliance with the prescribed medication regimen
D) Compliance with the prescribed medication regimen The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.
Initial sign of ICP (CH45)
Decreased LOC
Sign of basilar skill fracture (CH45)
Ecchymosis over the mastoid With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.
Tensilon test (CH46)
Used to diagnose MG and to differentiate between myasthenic crisis and cholinergic crisis.
Myopia (CH48)
nearsightedness- distant objects appeared blurred
emmetropia (Ch49)
normal vision
Hemorrhagic stroke (CH47)
occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed
TIA stroke
Tia has absence of residual s/s.
Subdural Hematoma (SDH) (CH45)
a mass of blood between the dura mater and the arachnoid mater of the brain; the most common type of traumatic brain injury (TBI)
Ischemic stroke (CH47)
a type of stroke that occurs when the flow of blood to the brain is blocked
Aphakia (CH49)
absence of the natural lens of the eye (usually resulting from the removal of cataracts)
Ocular emergency (Ch49)
acute angle- closure glaucoma
Presbycusis (CH48)
age related hearing loss
Decorticate posturing (CH45)
characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex.
Mydriasis (Ch49)
dilation of the pupil
Decebrate posturing (CH45)
extension and outward rotation of upper extremities and plantar flexion of feet.
presbyopia (CH48)
farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.
Apraxia (Ch47)
inability to perform particular purposive actions, as a result of brain damage.
cones (CH49)
retinal receptor cells that are concentrated near the center of the retina and that function in daylight or in well-lit conditions. The cones detect fine detail and give rise to color sensations.
Monro-Kellie hypothesis
theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents—brain tissue, blood, or cerebrospinal fluid—causes a change in the volume of the others; also referred to as Monro-Kellie doctrine
Low vision (CH49)
visual acuity between 20/70 and 20/200
Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer? (CH48) A) Photorefractive keratectomy (PRK) B) Laser-assisted stromal in situ keratomileusis (LASIK) C) Keratoconus D) Keratoplasty
B) Laser-assisted stromal in situ keratomileusis (LASIK) LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is a cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue.
The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? (CH46) A) Apply warm or cool cloths to the forehead or back of the neck B) Maintain hydration by drinking eight glasses of fluid a day C) Perform the Heimlich maneuver D) Use pressure-relieving pads or a similar type of mattress
A) Apply warm or cool cloths to the forehead or back of the neck Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.
A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? (CH46) A) Transesophageal echocardiogram (TEE), troponin levels, and a complete blood count B) EEG, blood cultures, and neuroimaging studies C) X-ray of the brain, bone marrow aspiration, and EEG D) Electrocardiography, TEE, prothrombin time (PT), and International Normalized Ratio (INR)
B) EEG, blood cultures, and neuroimaging studies Physicians use EEG and neuroimaging studies to diagnose neurologic problems. Blood cultures can identify infection that can cause seizures. Electrocardiography, TEE, and troponin levels are cardiac-specific diagnostic tests. X-ray of the brain reveals skeletal condition. Bone marrow aspiration isn't indicated for seizure disorder. PT and INR reflect blood coagulation.
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? (Ch46) A) Warm, dry skin B) Urine output of 40 ml/hour C) Soft, nondistended abdomen D) Even, unlabored respirations
D) Even, unlabored respirations A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness, evidenced by even, unlabored respirations, is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although warm, dry skin; urine output of 40 ml/hour; and a soft, nondistended abdomen are pertinent assessment data, those related to respiratory function and status are most significant.
Which terms refers to blindness in the right or left half of the visual field in both eyes? (CH47) A) Scotoma B) Diplopia C) Nystagmus D) Homonymous hemianopsia
D) Homonymous hemianopsia Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following? (Ch46) A) Dyskinesia B) Bradykninesia C) Micrographia D) Dysphonia
A) Dyskinesia Most clients within 5 to 10 years of taking levodopa develop a response to the medication called dyskinesia, manifested as facial grimacing, rhythmic jerking movements of the hands, head bobbing, chewing and smacking movements, and involuntary movements of the trunk and extremities. Bradykinesia refers to an overall slowing of active movement and is a manifestation of the disorder. Micrographia refers to the development of small handwriting as dexterity declines with Parkinson's disease. Dysphonia refers to soft, slurred, low-pitched, and less audible speech that occurs as the disorder progresses.
Which of the following, if left untreated, can lead to an ischemic stroke? (Ch47) A) Atrial fibrillation B) Cerebral aneurysm C) malformation (AVM) D) Ruptured cerebral arteries
A) Atrial fibrillation Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.
A patient is being actively treated for increased intracranial pressure (ICP) in the neurological intensive care unit. The patient's current plan of care includes pharmacological interventions to reduce cellular metabolic demand. The nurse should be aware that this may involve the administration of: (CH45) A) Barbiturates B) Benzodiazepines C) Anticholinergics D) Beta-adrenergic blockers
A) Barbiturates Cellular metabolic demands may be reduced through the administration of high doses of barbiturates if the patient is unresponsive to conventional treatment. Benzodiazepines are not used to achieve a reduction in metabolic demand. Anticholinergics and beta blockers do not have this effect.
A nurse is caring for a client diagnosed with Guillain-Barré syndrome. The client states, "It's getting harder to take a deep breath." Which action by the nurse is most appropriate? (Ch46) A) Call the physician and prepare for intubation. B) Explain the progression of the syndrome. C) Assess lung sounds. D) Encourage the client to cough.
A) Call the physician and prepare for intubation The progression of Guillain-Barré syndrome leads to neuromuscular respiratory failure in a large proportion of the people affected. Changes in vital capacity and negative inspiratory force are usually key indicators to be monitored for early intervention. The nurse should be alert to the earliest signs that a client may be heading toward respiratory failure. Explaining the progression of the syndrome will not change the potential need for mechanical ventilation due to respiratory failure. Because the respiratory failure is caused by neurologic changes, assessing the lung sounds, although appropriate, is not the highest priority . Encouraging the client to cough will not change the progression of the syndrome.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? (CH47) A) Cardiogenic emboli B) Cerebral aneurysm C) Arteriovenous malformation D) Intracerebral hemorrhage
A) Cardiogenic emboli Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
Assessment of a client's pupils reveals a size difference of 0.5 mm. Both pupils respond equally to light. The nurse documents this finding as: (Ch48) A) physiologic anisocoria. B) diplopia. C) conjunctivitis. D) red reflex.
A) physiologic anisocoria. Approximately 20% of the population may have pupils that are slightly unequal in size but respond equally to light. The term for unequal pupils is physiologic anisocoria, and it can be a benign variant (usually less than 1 mm difference between pupils). Diplopia refers to double vision. Conjunctivitis refers to an inflammation of the conjunctiva. The red reflex is the orange glow that is observed as light is applied to the pupil with direct ophthalmoscopy.
Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests? (CH48) A) Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss B) Conducting various tests to determine the function and the structure of the eyes C) Determining if further action is warranted D) Advising the patient on the diet and exercise regimen to be followed
A) Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Although nurses may not be directly involved in caring for patients who are undergoing eye examinations and tests, it is essential that they ensure that patients receive eye care to preserve their eye function and/or prevent further visual loss. The nurse is not involved in conducting the various tests to determine the status of the eyes and in determining if further action is warranted. Patients who are to undergo eye examinations and tests are not required to modify their diet and exercise regimen.
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first? (CH46) A) Initiate isolation precautions. B) Ensure the family receives prophylaxis antibiotic treatment. C) Administer prescribed antibiotics. D) Apply a cooling blanket.
A) Initiate isolation precautions The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? (Ch47) A) Ischemic B) Hemorrhagic C) Right-sided D) Left-sided
A) Ischemic Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.
A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? (CH45) A) Maintain a diet for the client that is high in protein, vitamins, and calories. B) Avoid range of motion exercises for the client because of spasms. C) Keep accurate intake and output. D) Watch closely for signs of urinary tract infection
A) Maintain a diet for the client that is high in protein, vitamins, and calories. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? (CH45) A) Monro-Kellie B) Cushing's C) Dawn phenomenon D) Hashimoto's disease
A) Monro-Kellie The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerbral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hasimoto's disease is related to the thyroid gland.
The most common cause of cholinergic crisis includes which of the following? (CH46) A) Overmedication B) Infection C) Undermedication D) Compliance with medication
A) Overmedication A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? (Ch46) A) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. B) Suggest applying cool compresses on the face several times a day to tighten the muscles. C) Inform the patient that the muscle function will return as soon as the virus dissipates. D) Tell the patient to smile every 4 hours.
A) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.
A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? (CH47) A) The woman's stroke has a hemorrhagic etiology. B) The woman is older than 80 years of age. C) The woman has previously had a stroke. D) The woman has hypertension and type 1 diabetes.
A) The woman's stroke has a hemorrhagic etiology. tPA is contraindicated in hemorrhagic stroke because it would greatly exacerbate cerebral bleeding. Older age, previous stroke, hypertension, and diabetes do not necessarily contraindicate the use of tPA.
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? (CH48) A) "Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces?" B) "Do you currently take sedatives, tranquilizers, or antihistamines on a regular basis?" C) "Do you have a history of falls or problems with loss of balance?" D) "Do you have a history of either high or low blood pressure?"
B) "Do you currently take sedatives, tranquilizers, or antihistamines on a regular basis?" Electronystagmography measures changes in electrical potentials created by eye movements during induced nystagmus. Sedatives, tranquilizers, and antihistamines suppress the vestibular system in the inner ear, leading to unreliable test results. These medications should be withheld for 24 hours prior to testing. Claustrophobia is not a significant concern associated with this test; rather, it is most often a concern for patients undergoing magnetic resonance imaging (MRI). Balance is impaired by Ménière's disease, therefore a patient history of balance problems is important; however, it is not relevant to test preparation. Hypertension and hypotension, while important health problems, should not be affected by this test.
The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following? (CH48) A) Pupillary reacton B) Extraocular muscle function C) Eyelid drooping D) Eyeball oscillation movements
B) Extraocular muscle function The nurse is testing the client's extraocular eye muscle function by having the client follow an object through the six cardinal directions of gaze (up, down, right, left, and both diagonals). Pupillary reaction is tested using a penlight. The nurse observes the position of the eyelids for drooping. The nurse asks a client to stare at an object and then each eye is covered and then uncovered quickly while the examiner looks for any shifts in the eye and oscillations in the eyeball.
Which is the most common cause of acute encephalitis in the United States? (Ch46) A) Western equine virus B) Herpes simplex virus C) West Nile virus D) St. Louis virus
B) Herpes simplex virus Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but they are not the most common causes of acute encephalitis.
A female patient with a profound visual deficit is unable to read the largest E on the Snellen chart. How should the nurse proceed with assessment of the patient's visual acuity? (CH48) A) Document the fact that the patient does not have functional vision. B) Hold up a random number of fingers in front of the patient's eyes and ask her to count them. C) Give the patient a hand-held version of the Snellen chart and have her hold it at the furthest distance at which she can read it. D) Ask the patient to identify the contents of a picture in a book or magazine.
B) Hold up a random number of fingers in front of the patient's eyes and ask her to count them. If the patient cannot see the letter E at any distance, the examiner should determine if the patient can count fingers (CF). The examiner holds up a random number of fingers and asks the patient to count the number he or she sees. If the patient correctly identifies the number of fingers at 3 feet, the examiner would record CF/3′. It would be inaccurate to conclude that the patient has absolutely no functional vision.
Loud, persistent noise has what effect on the body? (CH48) A) Dilation of peripheral blood vessels B) Increased blood pressure C) Decreased heart rate D) Decreased gastrointestinal activity
B) Increased BP Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure, increased heart rate, and increased gastrointestinal motility.
The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? (CH46) A) Change in level of consciousness B) Vomiting C) Vector bites D) Seizures
C) Vector bites Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in level of consciousness (LOC), vomiting, and seizures are all symptoms of increased intracranial pressure (ICP) and do not assist in the differentiating of cause, diagnosis, or establishing nursing care.
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? (CH45) A) Position the client in the supine position B) Maintain cerebral perfusion pressure from 50 to 70 mm Hg C) Restrain the client, as indicated D) Administer enemas, as needed
B) Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.
Which group of medications causes pupillary constriction? (CH49) A) Mydriatics B) Miotics C) Beta-blockers D) Adrenergic agonists
B) Miotics Miotics cause pupillary constriction. Mydriatics cause pupillary dilation. Beta-blockers decrease aqueous humor production. Adrenergic agonists increase aqueous outflow but primarily decrease aqueous production with an action similar to that of beta-blockers and carbonic anhydrase inhibitors.
There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for: (CH49) A) Tonometry. B) Ophthalmoscopy. C) Gonioscopy. D) Perimetry.
B) Ophthalmoscopy. Four major types of examinations are used in glaucoma evaluation, diagnosis, and management: tonometry to measure the IOP, ophthalmoscopy to inspect the optic nerve, gonioscopy to examine the filtration angle of the anterior chamber, and perimetry to assess the visual fields.
The nurse teaches the client with which disorder that the disease is due to decreased levels of dopamine in the basal ganglia of the brain? (CH45) A) Multiple sclerosis B) Parkinson disease C) Huntington disease D) Creutzfeldt-Jakob diseas
B) Parkinson disease In some patients, Parkinson disease can be controlled; however, it cannot be cured. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive and fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.
A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following? (CH49) A) Streptococcus pneumonia B) Haemophilus influenzae C) Chlamydia trachomatis D) Staphylococcus aureus
C) Chlamydia trachomatis Common organisms isolated are Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Two sexually transmitted agents associated with conjunctivitis are Chlamydia trachomatis and Neisseria gonorrhoeae.
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? (Ch45) A) Decerebrate B) Decorticate C) Flaccid D) Rigid
C) Flaccid LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68). An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate (Fig. 66-1; see also Chapter 65). The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been administered pharmacologic paralyzing agents (i.e., neuromuscular blocking agents).
One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following? (CH46) A) Sensory symptoms B) Motor symptoms C) Impaired consciousness D) Compound forms
C) Impaired consciousness A complex partial seizure is characterized by complex symptoms with the impairment of consciousness. A simple partial seizure generally occurs without impairment of consciousness.
A male patient with a history of poorly controlled type 1 diabetes has experienced an accelerated deterioration in his vision and is now considered to be legally blind. When planning this patient's care, the nurse should recognize the possibility of what nursing diagnosis? (CH49) A) Unilateral neglect B) Decisional conflict C) Ineffective coping D) Moral distress
C) Ineffective coping Although every patient will respond differently to a decrease in visual acuity, ineffective coping has been identified as a common phenomenon. This is more likely than unilateral neglect, moral distress, or decisional conflict.
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? (Ch45) A) Solid food with thin liquids B) Pureed food with water C) Semisolid food with thick liquids D) Thin liquids only
C) Semisolid food with thick liquids A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient
The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual field. (CH48) A) Clear cornea B) Constricted pupil C) Marked blurring of vision D) Watery ocular discharge
C)Marked blurring of vision Glaucoma is often called the "silent thief of sight" because most patients are unaware that they have the disease until they have experienced visual changes and vision loss. The patient may not seek health care until he or she experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.
The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF? (CH47) A) 45 to 50 mL/100 g/min B) 35 to 45 mL/100 g/min C) 35 to 45 mL/100 g/min D) 15 to 20 mL/100 g/min
D) 15 to 20 mL/100 g/min Cerebral blood flow of less than 25 mL/100g/min is the threshold for electrical failure. Refer to Figure 47-4 in the text.
A client with a spinal cord injury has full head and neck control when the injury is at which level? (Ch45) A) C1 B) C2 to C3 C) C4 D) C5
D) C5 At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.
Which statement is consistent with acute otitis media? (Ch48) A) The infection usually lasts more than 6 weeks. B) It is a relatively uncommon childhood infection. C) It is usually caused by a fungal infection. D) Conductive hearing loss may occur.
D) Conductive hearing loss may occur. Approximately three in four children experience an ear infection by the time they are 3 years of age. The infection usually lasts less than 6 weeks. Conductive hearing loss may occur due to a purulent exudate. Bacteria and viruses, not fungi, are the most common causes of otitis media.
A patient has severe shoulder pain from subluxation of the shoulder is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what? (CH47) A) Use of a sling should be avoided due to adduction of the affected shoulder. B) Elevation of the arm and hand can lead to further complications associated with edema. C) Passively exercising the affected extremity is avoided to minimize pain. D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The use of a properly worn sling when the patient is out of bed prevents the paralyzed upper extremity from dangling without support. Range of motion exercises are still vitally important in preventing a frozen shoulder and ultimate atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand
