PVN 141 NEURO

The nurse notices that a patient was diagnosed with otosclerosis after undergoing a Weber's test, Rinne's test, and tympanometry. Which findings should the nurse correlate with the test results. Select all that apply

-Lateralization of sound noted only in the affected ear -Evidence of stiffness in the patient's sound conduction system -Bone-conducted sounds are heard longer than air-conducted sounds

A nurse is preparing a patient for surgery to remove bilateral cataracts. Which statement made by the patient indicates a need for further teaching?

"I will require corticosteroid eye drops for the rest of my life."

A patient reports seeing flashing lights and floaters and a dark area in the outer peripheral vision. What is the most important question to ask for suspision of retinal detachment?

"Is the darkened area getting progressively larger?

A patient is suspected of having a retinal detachment. What signs/symptoms will provide support to this diagnosis? Select all that apply

"It feels like I'm looking through cobwebs." "I see specks floating around the edges of my vision." "I feel like someone pulled a curtain over my eye."

A client is scheduled for arthroscopic knee surgery and asks the nurse about the procedure. Which statement by the nurse best describes the procedure?

"It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it."

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response?

"Tetrahydrocannobinol is an ingredient in marijuana that decreases nausea and vomiting in some people."

A client exhibits blurred vision and double vision with muscular weakness, and diagnostic tests are prescribed. the client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respod?

"That must have really shocked you. Tell me what the health care provider told you about it."

A miotic medication has been prescribed for the client with glaucoma. the client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose?

"The medication causes the pupil to constrict and will lower the pressure in the eye."

A client is newly diagnosed with multiple sclerosis. the client is obviously upset with the diagnosis and asks, "am I going to die? What is the nurse best response?

"The prognosis is variable; most individuals experience remissions and exacerbations."

The nurse overhears a nursing student giving advice to a patient to "get a hearing aid." What is the best response that the nurse could give to the student and the patient?

"The type of hearing loss must first be determined because the device won't work for all types of hearing loss."

Which instructuction does the nurse repeat to a patient who is prescribed meclizine hydrochloride (antivert) Select all that apply

-"Abstain form alcohol" -"avoid taking central nervous system (CNS) depressants"

The caregivers of a patient with acute seizures ask the nurse what they should do if another episode of seizure occurs at thome after discharge. Which instructions should the nurse provide in response to the question? Select all that apply

-"Loosen constrictive clothes." -"Ease the patient to the floor." -"Protect the patient from any injury."

The caregivers of a patient with acute seizures ask the nurse what they should do if another episode of seizure occurs at home after discharge. What should the nurse tell them? Select all that apply.

-"loosen constrictive clothes" -"Ease the patient to the floor." -Protect the patient form any injury"

Which of the following are risk factors for glaucoma?

-Age over 40 years - Diabetes -High blood pressure

The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply

-Best verbal response -Best motor Response -Best eye-opening response

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern?

-Bleeding from the ears

A healthcare provider determines that the client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply

-Double vision -difficulty swallowing saliva -drooping of the upper eyelids

A 15-year-old hearing-impaired patient is having problems communicating with the staff. Which behavior would improve communication? Select all that apply

-Facing the patient when speaking -Speaking in conversational tones -Asking permission to turn off the television or radio

The nurse is orienting the patient to the hospital environment. He is just learning to use a cane as an assistive device for partial blindness. Which interventions would the nurse use? Select all that apply

-Suggest that the cane be used to identify borders or objects in pathways. -Advice to walk slowly, especially since the environment is unfamiliar -Describe the general layout of the room and the adjacent hallway.

A patient is scheduled for a stapedectomy. What postoperative instructions should the nurse include in patient teaching? Select all that apply

-Teach the patient to open the mouth when sneezing or coughing. -Limit exercise or active sports for 3 weeks -Avoid exposure to people with upper respiratory tract infections

What are the signs/symptoms of ectropion? Select all that apply

-Tearing -Redness of sclera -Corneal dryness -Outward turning of eyelid margin

When using the Snellen chart, what does a vision evaluation of 20/50 mean?

-The patient can read at 20 feet what most people can read at 50 feet. -The patient can read at 50 feet what most people can read at 20 feet.

Which patient is at higher risk of developing secondary Sjogren's syndrome? Select all that apply

-The patient who has a diagnosis of scleroderma -The patient who has systemic lupus erythematosus -The patient whohas a history of rheumatoid asrthitis

The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply

-Vision may be cloudy -Complaints of a burst of black spots or floaters

Which factors have been associated with the formation of cataracts? Select all that apply

-aging -smoking -ultraviolet light -diabetes mellitus -exposure to maternal rubella

A client with osteomyelitis has a slow rate of healing. Which factors can contribute to reduced healing in the client? Select all that apply

-diabetes -smoking -alcoholism

Which assessesment finding would indicte a need for possible glaucoma testing? Select all that apply

-halos around lights -Progressive loss of peripheral vision -Lack of ability to adapt to darkness

A nurse is teaching the parents of a child with juvenile idiopathic arthritis how to prevent loss of joint function. Which activities should be encouraged? Select all that apply

-riding a bicycle -Walking to school -Swimming in the community pool

What is the score in the Glasgow Coma Scale when the client has no eye response after a head injury?

1

A client who has been experiencing double vision, drooping of the eyelids, and fatigue visits the neurologic clinic. A diagnosis of myasthenia gravis is made, and the healthcare provider prescribes pyridostigmine. The nurse should teach the client that it is important to take this drug based on what schedule?

At the exact time intervals prescribed

A licensed practical nurse (LPN) is reviewing the medication list of the client with a history of glaucoma. The LPN should consult with the registered nurse if which medication is prescribed for the client?

Atropine sulfate

Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?

Atropine sulfate

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?

Atropine sulfate -Myadriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client has moderate to severe anxiety. Which action should the nurse take initially?

Attempt to discover what the client is concerned about

A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. Which action should the nurse take initially

Attempt to discover what the client is concerned about.

A client with myasthenia gravis is to receive immunosuppressive therapy. What assures the nurse that this therapy will be effective?

Decreases the production of autoantibodies that attack acetycholine resceptors

When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?

Detached retina

A patient with long-term, poorly controlled type 2 diabetes mellitus comes to the clinic complaining of tingling and burning in the legs and numbness in the toes. The nurse anticipates which diagnosis?

Diabetic neuropathy

A patient with type 1 diabetic mellitus states, "I know I'll go blind within 1o years. Why should I bother controlling my blood sugar?" Which information would the nurse provide to the patient regarding blindness and diabetes?

Diabetic retinopathy occurs more frequently in patients with long-standing, poorly controlled diabetes mellitus

A nurse is caring for a patient with myasthenia gravis. The nurse knows weakness of which muscles is the most dangerous complication of myasthenia gravis?

Diaphragm

A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates that the health care provider will prescribe the intravenous administration of what?

Diazepam

A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion?

Difficulty breathing

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that which characteristic is common to both crises?

Difficulty breathing

Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts?

Difficulty driving at night

A nurse is caring for two clients. One has Parkinson disease and the other has myasthenia gravis. For what common complication associated with both disorders, should the nurse assess these clients?

Difficulty swallowing

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical findings is the nurse most likely to identify>

Difficulty swallowing saliva

A client returns to work as a carpenter after surgery for carpal syndrome of the right hand. What instructions should the nurse give to help prevent further problems with the hands when the client returns to work?

Do stretching exercises during breaks

which neurotransmitter primarily affects motor function and is involved in gross subconscious movements of the skeletal muscles?

Dopamine

The patient is given a functional vision assessment (American Foundation for the Blind), and even with corrective lenses, the patient is unable to complete the distance task. For which task is the patient most likely need assistance?

Driving to a clinic appointment

A client had a spinal anesthesia for surgery. On the second day after surgery the client complains of a headache. What should the nurse do?

Encourage the client to drink at least 2L of fluids in 24 hours

Which synovial joint movement is described as turning the sole outward away from the midline of the body?

Eversion

Which clinical indicators does the nurse expect to identify when assessing a client with tic douloureux? Select all that apply.

Excruciating facial pain Twitching of the mouth

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique?

Exercise daily

A patient has impaired hearing. Which action by the nurse would best facilitate communication?

Face the patient when speaking

Which of the following methods is correct for examining the ear of an adult patient with an otoscope?

Gently pull the auricle up and back.

Tonometry is used in the diagnosis of which condition?

Glaucoma

A client who is legally blind is admitted to the hospital for surgery. What nursing action is most appropriate when caring for this client?

Keep the furniture in the same location in the room

Which intervention applies to positioning the patient after a stapedectomy?

Keep the operative side facing upward.

Which inference can the nurse make from observing a patient who reports severe eye pain related to blepharospasm?

Keratitis

The nurse is collecting data on a patient who tested positive on Schirmer's test. Which condition would the nurse observe in the patient?

Keratoconjuctivitis sicca

Which is a sign of acute angle closure glaucoma (AACG)?

Large fixed pupil

A nurse finds a victim under a wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first?

Leave the individual lying on the back with instructions not to move, and leave to seek additional help

A client who had a right total hip replacement is progressing form the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane?

Left hand

How should the nurse advise a patient who has severe vertigo from labyrinthitis?

Lie immobile and hold the head in one position until the vertigo lessens.

The nurse has reinforced instructions to a client regarding the method for instilling eye drops into the left eye. The nurse determines that the client needs further teaching if the client does which during a return demonstration?

Lies supine, pulls up on the upper lid, and puts the drop in the upper lid

Following cataract surgery, which activity is the ophthalmologist most likely to discourage?

Lifting a grandchild

A patient arrives in the emergency room after an accident that resulted in a piece of metal penetrating the eye. What nursing action should be taken initially on the patient's arrival at teh hospital?

Lightly cover both eyes with an eye sheild

A client is scheduled for a laminectomy. What should the nurse review with this client preoperatively?

Logrolling technique

Which of the following are causes of cataracts? (Select all that apply.)

Long-term use of corticosteroids Diabetes mellitus Smoking

The nurse is assigned to care for a client hospitalized with meniere's disease. The nurse expects that which would most likely be prescribed for the client?

Low-sodium diet

A client who has just been diagnosed with glaucoma has been given a prescription for a miotic medication. When reinforcing instructions to the client about medication effects, the nurse plans to tell the client that the medication works in which manner?

Lowers intraocular pressure and enhances blood flow to the retina

A 65-year-old patient reports visual deficits, including disturbances in color vision and visual clarity, and a darkened area in the center of vision. What medical diagnosis does the nurse anticipate will be made?

Macular degeneration

On reviewing the medical reports of a patient with swimmer's ear, the nurse finds that the patient also has cellulitis. Which medication would the nurse expect the health care provider to prescribe for the patient?

Neomycin (Mycifradin)

Which drug may cause formation of abnormally small eyes in the newborn if used during pregnancy?

Nitrofurantion

A nurse is taking care of a patient who suddenly begins to have a seizure. Which response by the nurse would be appropriate?

Observe and record the seizure activity.

A client is admitted to the hospital for cranial surgery. When the nurse develops the preoperative plan of care, what is included?

Obtaining the client's consent for shaving the head

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which action?

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

The nurse is reviewing the history of a patient with diabetes and finds that the patient has diabetic retinopathy. Which treatment would the health care provider prescribe to ensure the patient's safety?

Photocoagulation

Which action should the nurse take while preparing a 9-year-old child for the Snellen test?

Place the child at a distance of 20 feet from the chart.

The nurse's toddler received a prescription for antibiotics to treat acute otitis media. The antibiotics and acetaminophen where given as recommended, but the toddler is still crying with pain. What should the nurse try first?

Place the warm compress over the affected ear

The nurse is caring for a patient with glaucoma who is receiving mannitol (Osmitrol). Which level would the nurse regularly monitor in the patient?

Potassium

A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?

Press the end of the residual limb against a pillow periodically

A client has a paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every one to two hours?

Prevent pressure ulcers

These conditions may contribute to otitis media EXCEPT:

Prolonged exposure to loud noise

The nurse notes that a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure. What is the priority nursing responsibility at this time?

Protecting the child from self-injury

While caring for a patient who has swimmers' ear, the nurse notices greenish, watery discharge with a distinct odor from the patient's ear. Which organism would the nurse suspect?

Pseudomonas aeruginosa

The nurse assists the healthcare provider in performing a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the healthcare provider to document?

Queckenstedt

The nurse hears in the shift report that the patient has diplopia. Which task will be the most difficult for the patient?

Reading an information brochure

A client with rheumatoid arthritis ask the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question?

Reduces inflammation

What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid?

Reinsert the ear mold

A patient comes to the clinic complaining of new-onset flashes of light in the right eye along with floater, a dark area in the lower right visual field. Which diagnosis would the nurse anticipate?

Retinal detachment

The nurse prepares a patient for lumbar puncture. Which position is the most preferable for the patient?

Side-lying, with head and knees flexed at an angle

A client has diskectomy and fusion for a herniated nucleus pulposis. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. The nurses assisting with the ambulation should have the client do what?

Sit on the edge of the bed so they can hold the client upright

When providing discharge teaching to a client who had a total hip replacement, what should hte nurse instruct the client to avoid?

Sitting in a low chair

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. The nurse explains that the abilities that will be affected include what?

Stating wishes verbally

A patient with myopia is thinking about having refractory surgery to correct the problem. What should the patient do prior to the surgery?

Stop wearing contact lenses for 1-2 weeks before surgical evaluation

The home health nurse is supervising a parent who is demonstrating care for her child's conjunctivitis. The nurse would intervene if the mother performed which action?

Taped an eyepad loosely over the affected eye

The nurse is caring for a client who is suspected of having a brain tumor who is scheduled for a computed tomography (CT) scan. The nurse expects that the pre-procedure plan of care will include what?

Telling the client about what to expect during the examination

What should a patient who has had a cataract repair avoid?

The lifting of heavy objects

What is the first indication of macular degeneration?

The loss of central vision

The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?

The nurse would need to determine how this patient's visual impairment affects normal functioning.

A cleint is ready to walk with crutches after knee surgery. Which crutch-walking technique will the nurse most likely need to reinforce after the client returns from physical therapy?

Three-point

A client has primary open-angle glaucoma. The nurse expects that the client will receive a prescription for which eye drops?

Timolol maleate

Which antiepileptic drug can cause photophobia?

Trimethadione

The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to:

damage of the fine hair cells in the organ of Corti.

The nurse is providing postoperative care to the client that had surgery in which a hip prosthesis was inserted. An abductor splint is in place. When should the nurse remove the splint?

during the client's skin care and physical therapy

The home health patient complains of tearing and a feeling of dryness in the right eye. The nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n)_________________.

entropion

The nurse will assess for _____________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain.

external otitis

When assessing a client, the nurse identifies that the client has weakness of some of the muscles of the body. What should the nurse document in the medical record when muscles of the body. What should the nurse document in the medical record when describing weakness in the area indicated in the shaded portion of the illustration?

hemiparesis

The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone:

louder in his affected ear.

Pilocar tremorsdecadron sulamyd garamycin diamox

muscle tremors secondary eye infection pruritus secondary eye infection diarrhea

This is the surgical incision into the eardrum with either a knife or a heated wire loop to relieve pressure in the middle ear.

myringotomy

This is the term for the progressive deafness caused by the ankylosis of the stapes.

otosclerosis

Identify Common side effects of the listed Ear medications: Dramamine Antivert VoSol Hcl Otic Amoxil Cotisporin

painful urination dry mouth contact dermatitis diarrhea contact dermatitis

The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK:

removes some internal layers of the cornea

Which drug will most likely cause the client's eyelids to itch and eyes to burn as side effects?

vidarabine Vidarabine is an antiviral agent that causes sensitive reactions such as itching eyelids and burning eyes.

A nurse is caring for a patient who has increased intracranial pressure (ICP) and is intubated and mechanically ventilated. The nurse knows endotracheal suctioning should be performed how often?

when the patient's oxygen level drops as result of respiratory secretions

What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media?

Avoid alcoholic beverages

The nurse is on a camping trip and one of the campers gets poked in the eye with a stick. The end of the stick is protruding from the eye. What should the nurse do first?

Cover the injured eye with a paper cup and patch the uninjured eye.

Which cranial nerve damage may lead to decrease in the client's olfactory acuity?

Cranial nerve 1

Assessment of the ears includes which of the following?

A. Inspection B. Palpation C. Examination with an otoscope

Arrange the parts of the eye from the exterior to the most interior. (Separate letters by a comma and space as follows: A, B, C, D)

B, C, F, E, D, A

Which term describes the ability of the eye to focus on objects at various distances?

Accomodation

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid

While collecting data, the nurse notices that the patient has esotropia. Which symptoms did the patient report?

Both of the patients eyes turn toward the nose

What does the cataract treatment of phacoemulsification involve?

Breaking the cataract with ultrasound

Place the nursing intervention in appropriate order for the immediate care of a patient with a penetrating wound of the eye.

C, A, D, B, E

What does diabetes retinopathy result from?

Capillaries in retina hemorrhage

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factors associated with glaucoma?

Cardiovascular disease

Which nursing care and the patient teaching is most appropriate for patient with external otitis?

Washing hands before and after changing cotton plugs

Upon assessing a newborn, the nurse finds that the newborn's eyes are closed with no eye movement. Also, the newborn's breathing is regular with no body movement. What does the nurse understand about the newborn's state?

Deep sleep

A client is treated with lorazepam for status epilepticus. What effect of lorazepam does the nurse consider therapeutic

Depresses the central nervous system (CNS)

A nurse is planning care for a patient with hearing loss who wears hearing aids. Which intervention would be most important to ensure the patient understands when others are speaking to him?

Ensure the patient;s hearing aids are turned on and in place

When examining the eyes, which of the following is an expected finding?

Equal pupils

Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care because these clients need to do what?

Have sameness and consistency in their environment

Which condition would the nurse suspect in a patient complaining of a scratchy eye, blurred vision, warmth and redness around the eye, and a small abcess at the base of the eyelashes?

Hordeolum

For which eye condition are patients most likely to try self-treatment with over-the-counter eyewear?

Hyperpia

A nurse is providing instructions for a client who is receiving phenytoin but has limited access to health care. What side effect is the basis for the nurse's emphasis on meticulous oral hygiene?

Hyperplasia of the gums

A nurse is caring for an 88-year-old patient with type 2 diabetes mellitus and hypertension who is receiving timolol maleate (Timoptic) for the treatment of primary open-angle glaucoma. The nurse knows tp be extra vigilant for which condition in this patient?

Hypoglycemia

After a cervical neck injury, a client is placed in a halo fixation device with a body cast. A statement that indicates that the client's concern about body image has been resolved successfully is:

I've gotten used to the brace. I may even miss it when it's gone."

The nurse understands that the reason that the clients are fitted soon after an amputation of limb usually is related to what?

Improving the client's physical abilities

A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position?

In bed with the head of the bed elevated

A nurse is caring for a client with a tumor of the cerebellum. What clinical manifestation does the nurse expect the client to exhibit?

Inability to execute coordinated movements

A client has a fever spike, but the client's body temperature returns to normal at least once a day. Which type of fever can be assessed in the client?

Intermittent

A client has a brain attack (cerebrovascular accident [CVA]) that involves the right cerebral cortex and cranial nerves. What areas of paralysis should the nurse expect the client to exhibit? Select all that apply.

Left leg Left arm

A client who has been taking diuretics is admitted to the hospital with hypokalemia. For which clinical findings should the nurse assess the client?

Leg weakness and muscle cramps

A client with the diagnosis of multiple sclerosis (MS) develops increased visual problems, progressive muscular weakness, and frequent episodes of emotional lability. The difficulties experienced are very distressing to the client. The client bursts into tears for no apparent reason while having a discussion with the nurse. What is the nurse's best response?

Let the client cry and then resume the discussion

A primary health care provider prescribes a diagnostic workup for a client who may have myasthenia gravis. The initial nursing goal for the client during the diagnosis phase is that the client will do what?

Maintain present muscle strength

After a 4-year old child under goes craniotomy the nurse performs a neurologic assesssment that includes level of consciousness, pupillary activity. What else should the nurse include in this assessment?

Motor function

A nurse is preparing to care for a patient with hemianopia. The nurse knows this results in the patient seeing which abnormality in the visual field?

Objects in only half of the field

A nurse is preparing a patient with suspected meningitis for a lumbar puncture to obtain cerebrospinal fluid for culture. How should the nurse position the patient for the procedure?

On the side with the knees and head flexed

Which muscle of the head and the neck facilitates the ability to draw the lips together?

Orbicularis oris

A 3-year-old patient is brought to the clinic with ear pain. The patient's mother reports that the patient gets swimmer's ear often during the summer. The nurse would document this as which condition?

Otitis externa

A nurse in the pediatric clinic observes an 11-month old boy who is sitting on his mother's lap crying and tugging at his right ear. What probable problem does this behavior indicate?

Otitis media

What is a common mistake that hinders communication when communicating with the hearing impaired?

Overaccentuating words

Which is a clinical manifestation of osteoarthritis?

Pain and stiffness of the joints

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response?

Panic

Which clinical indicator does a nurse identify when assessing a client with hemiplegia?

Paralysis of one side of the body

After a cerebrovascular accident (also known as brain attack), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Parietal

A nurse is contributing to the admission assessment of a patient who reports taking carbidopa-levodopa, selegiline, and pramipexole. On the basis of these prescription medications, the nurse knows the patient has which disorder?

Parkinson's disease

The patient shows loss and deterioration in the automated perimetry test. Which activity is the patient most likely to have difficulty with?

Participating in a basketball game.

Which patient is likely to be the best candidate for a hearing aid?

Patient has conductive hearing loss due to stenosis of the external auditory canal.

The nurse is reviewing the medication prescriptions for several patients with disorders of the eye. The nurse would question the health care provider about the use of corticosteroids for which patient?

Patient needs treatment for keratitis

A nurse is caring for a client who just had an above-the-knee amputation. that is the key factor in assessing how the client will cope with the body image change?

Personal perception of the change

A patient is to have a laser treatment to cauterize hemorrhaging vessels caused by a diabetic retinopathy. The patient asks the nurse what this procedure is called. Which response by the nurse is correct?

Photocoagulation

What must a patient do following a left vitrectomy?

Position self in a face-down position for 4 to 5 days

What type of visual distortion is associated with diabetic retinopathy?

Sudden onset of peripheral vision loss and eye discomfort

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache

A client sustains a back injury after falling 20 feet (6m). In which position should the nurse place the client?

Supine position while not allowing the spine to flex

The nurse assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves. Which action will the nurse ask the client to perform?

Swallow

A client with multiple sclerosis is in remission. Which activity should the nurse encourage that the best meets the client's needs while in remission?

Swimming

Which nursing intervention should be implemented immediately at onset of seizure to ensure the safety of a patient with tonic-clonic seizures?

Take measures to prevent head injury

A client sustains a fractured right femur in a fall on the ice and is admitted to the hospital's emergency department. How should the nurse assess this client for signs of circulatory impairment?

Take the client's pedal pulse in teh affected extremety

A client with dementia is admitted with a fractured hip following a fall at home. the client's family member witnessed the fall. Four hours after admission, the client's blood pressure increases to a moderately severe hypertensive level. The client pulls on the bedclothes continuously. The client's family member asks for pain medication for the client. What does the nurse conclude

The client may be in pain and inable to respond appropriately

Haloperidol 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered and agitated after a street brawl. What does the nurse conclude after reviewing the prescription?

The dose is more than recommended

Which statement about an otoscopy for a child is incorrect?

The ear is pulled slightly upward and backward

Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?

The lamp can cause cataracts.

The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a bubble of gas to put pressure on the damaged retina.

True

The nurse's neighbor is trying to remove an eyelash from her eye. The nurse would intervene if the neighbor used which methond?

Used a clean cotton- tipped swab to wipe the cornea

A back brace is prescribed for a client who had a laminectomy. Whatinstruction should the nurse include in teh teaching plan?

Apply the brace before getting out of bed

Which of the following would be most hazardous in the home of a patient who is visually impaired?

Area rugs

Which term most accurately describes age-related changes of neurologic system?

As neurons are lost with aging, there is deterioration in neurologic function

A nurse is planning care for a patient with dysphagia secondary to spinal cord injury. The nurse knows this patient is at risk for which serious complication?

Aspiration pneumonia

After a client has spinal surgery, what is the essential that he nurse does?

Assesses the client's feet for circulation and sensation

A 78-year-old patient comes into the clinic complaining of progressive loss of vision in the enter of the visual field. The nurse is aware that the patient is most likely experiencing symptoms of which disorder?

macular degeneration

The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at _______ feet.

40

The nurse use the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates the client is in a coma?

6

A client after a trauma has difficulty opening his or her eyes, has abnormal motor response, and speaks inappropriate words. What is the status of the client utilizing the Glasgow Coma Scale? Record your answer using a whole number:

8

A client is admitted to the emergency department with head trauma resulting from an accident. The nurse uses the Glasgow Coma Scare to determine the patient's neurologic function. The patient opens the eyes to painful stimuli, is able to speak but uses inappropriate words, and flexes away from pain. Which number should the nurse use to document the patient's neurological function?

9

When assessing a client with heart failure, the nurse asks when the client most notices an increase in symptoms. Which activity should the nurse expect will cause the client the greatest distress?

Climbing a flight of stairs to the bedroom

What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh?

Compress and release the toenails of the affected foot

Which visual disorder is characterized by slow, progressive loss of central and near vision?

Age-related macular degeneration (ARMD)

The Rinne and Weber tests measure which of the following?

Air and bone conduction

The otoscopic examination of a patient showed excessive secretion of cerumen in the left ear canal. Which medication would the nurse expect the health care provider to prescribe?

Carbamide peroxide (Debrox)

A patient visits the clinic complaining of blurry vision, difficulty driving at night, and sensitivity to light. The nurse notes that bilaterally the pupils looked opaque and milky. The nurse anticipates which diagnosis?

Cataracts

A nurse applies a cold pack to treat an acute musculoskeletal injury. How does cold therapy decrease pain?

Causing local vasoconstriction, preventing edema and muscle spasm

A patient has suffered hearing loss after a stroke. Which type of hearing loss would the nurse expect the patient to have?

Central hearing loss

A client who has open-angle (chronic) glaucoma is Scheduled for eye surgery to promote aqueous humor outflow. The nurse evaluates that the client understands the preoperative teaching about the first 24 hours after surgery when the client makes which statements?

"I should avoid coughing."

A practical nurse teaches a client with rheumatoid arthritis about precautions to be taken during the intake of methotrexate. Which statements made by the client indicates effective learning? Select all that apply.

"I should drink lots of water." "I should not plan to become pregnant."

The nurse is reviewing the patient's medication list and sees the patient takes meclizine. What instructions should be given to the unlicensed assistive personnel (UAP)

Assist the patient to ambulate because he gets dizzy

The nurse is repeating instructions to a patient with epilepsy about the care to be taken after discharge. Which statement made by the patient indicates the need for further teaching?

"I may stop taking my seizure medications if I have not had a seizure in 30 days"

The health care provider informs the nurse that the patient had an abnormal Romberg test. Which safety precaution will the nurse initiate?

Assist the patient to stand and get balance before walking

An 80-year-old client with dementia of the alzheimer type is admitted to a nursing home. A family member visits and remarks how thin and wrinkled the client has become. Which response by the nurse will help the family member most to understand and the aging process?

"As we age, we lose the tissue that helps puff out the skin."

The LPN/LVN is teaching a client regarding a newly diagnosed condition. The nurse states that the condition involves "uneven curvature of the cornea that leads to the inability of the retina to focus vision." Which of the following eye conditions does this statement represent?

Astigmatism

A 68-year-old African-American patient visits the clinic complaining of eye pain. On further questioning, the patient states, "I feel like I have tunnel vision. I've been running into things when I walk from outside into a darkened room. Also, every time I look at the tv or a lamp, I see a halo around the light." The patient is found to have increased intraocular pressure. The nurse anticipates which therapy will be prescribed?

Administration of betaxolol hydrocholride (Betopic)

Which condition causes senile cataracts?

Advancing age

Which client is most likely to be diagnosed with a benign brain tumor?

African american male

A client admitted to the hospital for a total hip replacement. The nurse is planning preoperative teaching about the nursing care to be delivered during the immediate postoperative period. Which is the most important factor that the nurse should focus on regarding immediate postoperative care?

Abducting the operative hip

What is the process when the lens of the eye changes its curvature to focus on the retina?

Accommodation

What term refers to the constriction of the pupils when a patient focuses on an object held about 10 centimeters from the nose?

Accommodation

The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take?

Administer the eyedrop first, followed by the eye ointment

A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/dL. Which action should the nurse take?

Administer the next dose of hte medication as prescribed

Based on research, supplemental zinc, betacarotene, vitamins C and E, and a diet rich in fruits and dark-green leafy vegetables would be recommended for which eye disorder?

Age related macular degeneration

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing?

Babinski

A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the health care provider?

Calcium supplements

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss equilibrium and coordination, the nurse suspects the tumor is located where?

Cerebellum

The nurse is admitting an adult patient to a walk-n clinic. the patient complains of recent hearing loss. What does the nurse anticipate as the most probable cause of this patient;s hearing loss?

Cerumen buildup

The nurse is caring for a client who has a tumor of the cerebellum. What is the client most likely to exhibit?

Inability to execute smooth movements The cerebellum is involved in the synergistic control of muscle action; it functions to produce smooth, steady, coordinated, and efficient movements. The cerebrum, not cerebellum, is responsible for the level of consciousness. The brain is not involved in a simple reflex arc. The cerebrum, not cerebellum, is responsible for voluntary motor function.

A client is admitted to the hospital with a severe head injury. What should the nurse identify as the priority nursing care for this client?

Maintaining respiratory exchange and ventilation

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure?

Maintaining the client in the supine position for several hours.

What is the priority nursing objective of the therapeutic psychiatric environment for a confused client?

Maintaining the highest level of safe, independent function

A patient comes to the clinic and is diagnosed with otitis media. The nurse understands that proper treatment is vital to prevent the spread of infection to which structure?

Mastoid process

What action should the nurse take when caring for a client who has possible skull fracture as a result of trauma?

Monitor the client for signs of brain injury

What are the current recommendations for ophthalmologic examinations? Select all that apply

-People between 40 and 64 years of age need examination every 2-4 years. -African Americans in every age group should have more frequent examinations -People 65 years of age or older should be examined every 1-2 years -People with diabetes mellitus should have more frequent examinations

What do miotic eyedrops do for a patient with glaucoma?

Constrict the pupil and open the canal of Schlemm

A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine is prescribed. When teaching the client about the medication, the nurse explains that the desired effect is to increase what?

Contraction of skeletal muscles

What does full movement of the eyes in the six cardinal fields of gaze reflect?

-Proper functioning of the oculomotor, trochlear, and abducens nerves - Proper functioning of the extraocular muscles

The mother of a 22-month-old toddler who has suffered from frequent otitis media (OM) infections asks the nurse what could cause these ear infections to reoccur so often. Select all that of the following that are normal characteristics of young children that predispose them to development of otitis media.

-Undeveloped cartilage lining the ear -Short eustachian tubes -Normal position of young children -Hormonal defense responses of young children

The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply

-Wash hands -Put on gloves _place the drop in the conjunctival sac -pull the lower lid down against the cheekbone.

The total removal of an eye is a(n) ___________.

enucleation

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid? The nurse recalls that the classification to which this drug belongs is what?

Analgesics

During an assessment, the nurse notes that the patient is able to speak but must point to areas that are causing pain instead of simply naming the body part. The nurse suspects which type of aphasia?

Anomic Aphasia

A patient who complains of severe ear pain has black discharge in the ear canal. The nurse anticipates which medication will be prescribed?

Antifungal

When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report?

Any distortion of the grid

The nurse is concerned that a client may experience systemic effects from a beta-blocker ophthalmic solution. The nurse realizes the client is able to self-administer the medication if the client instills the drops in which manner?

Applies digital pressure to the lacrimal sac for 1 to 2 minutes after instillation

A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?

Apply a pressure dressing over the right eye socket

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action?

Apply ice to the affected eye

Prescription of which of the following medications to a client with glaucoma should alert the LPN/LVN to clarify the order with the physician prior to admministration?

Atropine sulfate (Sal-Tropine)

A client is admitted to the hospital for surgery for an extracapsular cataract extraction with an intraocular lens implantation. What is most important to include in the teaching program regarding postoperative activities?

Avoid bending from the waist

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states that it is important to do what?

Avoid people with respiratory infections

A client with meniere's disease is experiencing severe vertigo. The nurse reinforces instruction to the client to do which to assist with controlling the vertigo?

Avoid sudden head movements

A 71-year-old patient complains of being severly dizzy. What instruction should the nurse give teh patient?

Avoid sudden movements

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. The primary consideration in the care of this client is the need for what?

Control of pain

A nurse reviews information for a client diagnosed with open-angle glaucoma. What should the nurse explain as being the chief aim of treatment?

Control the intraocular pressure

Which symptom in the client indicates late-stage brain herniation?

Cushing's response

A client's leg is placed in Buck's extension to immobilize a fracture until surgery can be performed. When caring for this client, the nurse understands that Buck's extension is a type of what?

Cutaneous traction

A nurse is collecting data on a client with Parkinson disease. Which findings support this diagnosis? Select all that apply.

Nonintention tremors Masklike facial expression Low-pitched monotonous voice

A client with a history of seizures is admitted with partial occlusion of the left common carotid artery. The client has been taking phenytoin for 10 years. When planning care for this client, what should the nurse do first?

Obtain a history of seizure type and incidence

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and hyphema has been diagnosed. Which position should the nurse prepare to position the client?

On bed rest in a semi-fowler's postion

A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the best initial action by the nurse?

Placing the child on the floor

A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. The nurse expects which procedure will be considered as a treatment option?

Plasmapheresis

The nurse is preparing to administer eardrops to an infant. How should the nurse administer the eardrops?

Pull down and back on the ear, and direct the solution toward the wall of the canal.

The nurse is preparing to administer eardrops to an adult client. the nurse administers ear drops by which technique?

Pulling the pinna up and back

Which term describes the thick, white opaques connective tissue that is part of the outermost layer of hte eyeball?

Sclera

A nurse is caring for a patient with a risk for increased intracranial pressure (ICP). This patient should remain in which position?

Semi-Fowler's

With Sjogren's syndrome, what would the nurse expect the patient to report?

Sensation of grit in the eyes

A provider is performing Weber's test on a patient who complains of hearing loss on the right side. The patient reports the sound is louder in the left ear. Which type of hearing loss does this demonstrate?

Sensorineural jhearing loss

A client who is receiving phenytoin to control a seizure disorder questions the nurse regarding this medication after discharge. How will the nurse respond?

"Antiseizure drugs will probably be continued for life"

A nurse is planning care for a patient who is legally blind. Which intervention for this patient would be most appropriate to complete activities of daily living (ADLs) and foster independence and self-confidence?

Set aside extra time to assist the patient with ADLs, as necessarry

For a patient who is diagnosed with keratitis, which common symptoms differentiates this disease from other inflammatory eye diseases?

Severe eye pain

A nurse is caring for a client with severe rheumatoid arthritis. What is most important in the nurse's approach to help this client self-reliance and independence?

A positive attitude toward the eventual outcome

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record?

A sense of a curtain falling across the field of vision

The nurse notes that the primary health care provider PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this contidion?

A sensorineural hearing loss that occurs with aging

The nurse is teaching a patient about dietary habits that can trigger cluster headaches. Which food item should the patient avoid?

Alcohol

A nurse is assisting the provider in testing the patient's cranial nerves. Which supplies would the provider need to test cranial nerve 1?

Alcohol swabs

While assessing a patient, the nurse asks the patient her name, the year, and the location. The patient's responses are significant for the correct name, incorrect year, and correct location. How should the nurse document the patient's responses?

Alert and oriented to person and place

When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?

American Foundation for the Blind for a list of agencies

What are the "four As" for which nurses should evaluate clients with suspected Alzheimer disease

Amnesia, Apraxia, agnosia, aphasia

A client's relative asks the nurse what a cataract is. What explanation should the nurse provide?

An opacity of the lens

A nurse advises a client to use a firm mattress for sleep and to refrain from sleeping on the abdomen. Which condition does the client most likely have?

Back sprain

Which joint helps in the gliding movement of the wrist?

Biaxial joint

During data collection, the nurse finds that the patient has pruritus, erythema of the eyelid, eyelid pain, excessive tearing, and difficulty seeing light. Which condition do these symptoms indicate?

Blepharitis

A client who just has been diagnosed with primary open-angle glaucoma (POAG) refuses therapy. The nurse reinforces that it is important for the client to seek treatment because if POAG is left untreated it may lead towhat?

Blindness

Which characteristics, if exhibited by the patient, would indicate to the nurse that the patient is at an increased risk for neurovascular disease?

Blood pressure 142/94 mm Hg

The nurse reinforces instructions to a client who has been prescribed betaxolol eye drops for the treatment of glaucoma. The nurse instructs the client regarding the administration of the medication and about the importance of returning to the clinic for which assessment?

Blood pressure and apical pulse

A patient has a family history of cataracts. He asks what early symptoms he should watch for that would alert him to the development of cataracts. What is the nurse's best response?

Blurred vision

Which sensory function will be impaired in a patient who has had a cerebrovascular accident (CVA) affecting the hypothalamus?

Body temperature

While collecting data, the nurse notices that the patient has esotropia. Which symptoms did the patient report?

Both of the patient's eyes turn toward the nose

A client newly diagnosed with myasthenia gravis is to begin taking pyridostigmine, a cholinesterase inhibitor. Two days later the client develops loose stools and increased salivation. What conclusion does the nurse make about these new developments?

Cholinergic effects

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does hte nurse idenetify as consistent with the diagnosis?

Cannot see an object in the center of the visual field

Which sign would be considered the earliest sign of increased intracranial pressure?

Change in level of consciousness (LOC)

During a home visit a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is unresponsive to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse beliefs that intervention by an appropriate community resources is indicated. Where should the nurse make a referral?

Child protective services

What does a tympanoplasty correct?

Conductive hearing loss

What therapeutic effect does the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edema?

Decreased intracranial pressure

What therapeutic effect does the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edeman?

Decreased intracranial pressure

What therapeutic effects does the nurse expect to clarify when mannitol is administered parenterally to a client with cerebral edema?

Decreased intracranial pressure

A nurse caring for a patient with a risk for increased intracranial pressure (ICP) knows to be vigilant for which early sign of increased ICP?

Decreased level of consicousness

What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply.)

Describe the surroundings Encourage the patient to ask for verbal cues Place patient hand on nurse's shoulder or elbow

Which nursing intervention should the nurse implement while preparing a patient suspected of having a brain tumor for computer tomography (CT) of the brain?

Determine whether the patient is allergic to iodine

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed?

Effectiveness of respiratory exchange and ability to swallow

What should the nurse include in the plan of care following a tympanoplasty?

Elevating head of bed with operative side facing upward

Why is otitis media found more frequently in children 6 to 36 months?

Eustachian tubes in children are shorter and straighter.

Initially after a stroke , a client's pupils are equal and reactive to light. Later, the nurse assess that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?

Increasing intracranial pressure

The nurse has a 10-year-old daughter who wants to invite two friends for a sleepover. Part of the entertainment for the night is to do "glamour makeovers." What should the nurse do?

Purchase three makeup kits from the drug store and supervise the activity

The nurse supports cognitive ability in clients with Alzheimer dementia, by doing what? Select all that apply.

Using calendars, clocks, and pictures to support memoryEncouraging caregivers to support protected independenceProviding a limited number of choices to support decision making

The nurse is caring for an elderly client who has a right hip fracture. What intervention should be included in the plan of care?

Venous thromboembolism prevention (VTE)

Which client is the nurse most likely to monitor for ankylosing spondylitis?

White male

A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for what early indicator of potential damage to the motor branch of the facial nerve?

simple wrinkling of the face

What action should the nurse take to prevent precipitating a painful attack in a client with tic douloureux?

Avoid walking swiftly by the client

What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply.)

Turn the patient to his right side Leave the bed flat Medicate immediately on the complaint of nausea

A nurse enters the room of a patient in bed who appears to be having a seizure. Which intervention should the nurse implement immediately?

Turn the patient's head to the side to protect the patient's airway.

Which response should the nurse expect a client diagnosed with cerebellum dysfuntion to exhibit?

Uncoordinated movements

Shoulder immobilization is prescribed after surgical repair of a client's rotator cuff. Which criterion should the nurse use to determine that appropriate alignment is achieved by the immobilizer device?

Upper arm lies close to the chest

A patient is diagnosed with an inner ear problem. For what symptom should the nurse monitor the patient closely?

Vertigo

A patient tells the nurse he has dizziness. He states that the health care provider used another term. What term did the health care provider most likely use?

Vertigo

What clinical indicator does the nurse expect to identify when assessing a client with a brain tumore in the occipital lobe?

Visual hallucinations

If there is a disturbance in proprioception, which function will the patient have difficulty performing?

Walking up the stairs

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider. Which action should the nurse plan to take?

Warm the irrigating solution to 98 F

A nurse is caring for a patient receiving carbidopa-levodopa for Parkinson's disease. Which instruction should the nurse give the patient to decrease the patient's risk of falling?

"Change position Slowly."

A patient diagnosed with labyrinthitis tells the nurse, "I often feel like the objects are moving around me." Which safety advice would the nurse give to the patient?

"Change positions slowly."

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene?

"Clients with decreased sensory perception to touch should b carefully monitored for infection

A nurse is providing instructions to a client with glaucoma. Which statements made by the client indicate the nurse needs to intervene? Select all that apply.

"I can lift objects that weigh more than 10 lbs (4.5 kg)." "I should keep my head in a dependent position."

The nurse is reinforcing instructions to a client with glaucoma receiving acetazolamide daily. Which statement by the client indicates an understanding of the adverse effects related to the medication?

"I need to call the doctor if I notice dark urine and stools."

A patient is asked to sign a surgical consent for treatment of otosclerosis. which statement indicates correct understanding of the procedure?

"It will help me hear sounds again."

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response?

"Pain is not a characteristic symptom of this contidion."

A client with multiple sclerosis is informed that this is a chronic, progressive neurological condition. The client asks the nurse, "Will I experience excruciating pain?" What is the nurse's best response?

"Pain is not a characteristic symptom of this disease conditon"

A nurse is providing education to a patient with a hordeolum in the right eye. Which instruction is most important for this patient?

"Perform hand hygiene immediately before and after contact with infected eye."

The patient has been diagnosed with a visual disorder. Contact lenses have been prescribed. Which statement indicates the need for further instruction?

"Photophobia, dryness, burning, or tearing are expected symptoms."

A nurse is providing education to a patient with bacterial conjunctivitis. How would the nurse best determine the patient's ability to perform the necessary treatments?

"Please show me how you will irrigate the infected eye and administer the medications."

A nurse is preparing a patient with detachment of the superior retina in the right eye for a pneumatic retinopexy. Which instruction is most important to ensure success of treatment?

"Remain upright for several weeks after therapy."

The nurse's teenage son tells him that his contact lens fell out while he was hanging out in the park with his friends, so he used saliva to clean it off. Which question should the nurse ask?

"So what are you planning to do if that happens again?"

The parents want to know more about their child's conductive hearing loss. Which is the best explanation by the nurse?

"Sound is delivered through the external and middle ear, but a defect in the inner ear results in distortion of sound."

The nurse is caring for a patient who underwent radial keratotomy (RK). Which discharge instructions would the nurse repeat to the patient?

"Wear dark sunglasses to decrease light sensitivity."

A client has a tonic-clonic seizure at work and is admitted to the emergency department which question is most useful when planning nursing care related to the client's seizure?

"Were you aware of anything different or unusual just before your seizure began?"

The nurse is teaching a patient about magnetic resonance imaging (MRI). Which statement should the nurse include in the teaching?

"You should remove any metal form your body or clotting."

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response?

"Your joints are still inflamed and physical therapy can be harmful."

While awaiting the biopsy report before removal of a tumor, the client reports being afraid of diagnosis of cancer. How should the nurse respond?

"it is very upsetting to have to wait for a biopsy report."

A client is admitted to the hospital with a diagnosis of mayesthenia gravis. For which common early clinical findings should the nurse assess the client?

Diplopia

Which instructions would the practical nurse reinforce when reviewing hearing aid care with a patient? Select all that apply

-Extra batteries and a cord should always be kept available -The ear mold should be reinserted if the hearing aid whistles -The ear mold or plug should be dried thoroughly before reconnecting

A whispered voice test includes which of the following?

-Having the patient wiggle a finger in the opposite ear. -Whispering while standing 1 to 2 feet from the patient's ear.

The nurse is caring for a patient with Meniere's disease complaining of recurrent episodes of vertigo, nausea, vomiting, and tinnitus. Which interventions should the nurse perform to relieve the symptoms? Select all that apply

-Limit fluid intake -Administer diuretics -Provide a low-salt diet

The nurse assesses a 65-year -old cluent's electronic medical records and notices a history of increased lens density. Which nursing actions will be most appropriate for this client? Select all that apply

-Monitoring the client's blood glucose levels -Assessing if the client is under antiplatelet medication

Which eye safety measures does the nurse keep in mind while caring for patients? Select all that apply

-Ophthalmic solutions that are cloudy should not be used -Hands should be washed before and after touching the eyes. -Dark glasses should be worn during prolonged exposure to bright light

A client with expressive aphasia becomes agitated and upset when attempting to communicate with the nurse. To help reduce the client's frustration, what should the nurse do?

Allow the client adequate time to speak

A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage?

Encourages a normal walking pattern

A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide therapy via tablets has been prescribed. The nurse anticipates that the dosage is being adjusted, what action does the nurse perform?

Evaluate the client's muscle strength every hour after the medication is given.

These conditions may cause conductive hearing loss EXCEPT:

Exposure to ototoxic drugs

the nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

Eye medications may need to be administered for the rest of your life

Mydriatics medications constricts the pupil of the eye.

False

On the first postoperative day after a total hip replacement a client asks for assistance onto the bedpan. What should the nurse instruct the client to do?

Flex the knee on the unoperated leg and pull on the trapeze to lift the pelvis

Which diagnostic test requires an assessment of allergies to seafood or iodine?

Flourescein angiography

What clinical finding does the nurse expect when assessing a client with myasthenia gravis?

Fluctuating weakness of muscles innervated by the cranial nerves

Which antiinfective agent may lead to blindness if not used correctly by the client in prescribed amounts?

Gentamicin

A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred?

Gradually

Four hours after a stapedectomy the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?

Hearing will not return until edema subsides

The nurse is collecting data on a child who is undergoing the Snellen test. Which assessment findings should the nurse report?

Inability to see the letters on the chart

A nurse is caring for a 75-year-old patient who has experienced come sensory deficits. Which change might be explained by age-related changes of the sensory system?

Increased difficulty focusing on close objects

During the neurological assessment of a client with tentative diagnosis of Guillain-Barre syndrome, what does the nurse expect that the client will manifest?

Increased muscular weakness

The nurse is caring for a visually impaired patient. Which action should the nurse take to reduce the risk of injury and anxiety in the patient?

Inform the patient every time before touching

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?

Installation of mineral oil or diluted alcohol

One of the housekeepers splashes a chemical in the eyes. What should be the first priority?

Irrigate with normal saline solution for 20 minutes

A client sustains a chemical eye injury form a splash of battery acid. The nurse should prepare the client for which immediate measure?

Irrigating the eye with sterile normal saline

The nurse is caring for a client who has been taking acetazolamide for glaucoma. The nurse reviews the assessment data documented in the client's medical record and determines that an adverse effect of the medication may be occurring if which result is noted?

Jaundice

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?

Keep skin lubricated with lotion

A nurse is providing postoperative teaching to a client who is scheduled to have an above-the-knee amputation. The client will use crutches during the postoperative period. Which activity will prepare the client for crutch walking?

Lifting weights

A client is diagnosed with the genetic disorder osteogenesis imperfecta. Which condition can be anticipated in the client at an age 30?

Loss of auditory acuity

What problem will the patient have if there is damage to the fine hair cell receptors in the organ of Corti?

Loss of hearing

A nurse obtains the health history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report what?

Loss of peripheral vision

A client has a tonic-clonic seizure caused by an overdose of aspirin. What is an appropriate nursing action?

Monitor vital signs every 15 minutes

Betaxolol hydrochloride eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?

Monitoring blood pressure

A client with a brain attack (cerebrovascular accident) is admitted to the hospital. What is the priority nursing intervention for this client?

Monitoring for increased intracranial pressure

Which medication should the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema?

Morphine

A nurse caring for a patient with nonneovascular macular degeneration knows to prepare the patient for which therapy?

None; there is no treatment

These factors must be considered by the nurse in assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired EXCEP

Occupation

A male patient has been recently diagnosed with Parkinson's disease. His wife asks the nurse numerous questions about the disease. Which information is correct in addressing this wife's questions?

Parkinson's disease is a syndrome of bradykinesia, tremor, and impaired postural reflexes

What is an early indicator of acute otitis media?

Patient reports ear pain and is pulling on teh pinna

A client was admitted tot he hospital with a direct injury to the vertebral column from a gunshot after a mass shooting. The nurse suspects a spinal cord injury. Which mechanism of injury might be the reason for hte injury?

Penetrating trauma

A nurse is inspecting the patient's ears with an otoscope. Which of the following findings would be considered abnormal?

Perforation of the tympanic membrane

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse do?

Perform a complete pain assessment

During the night, which strategy for environmental control is best to help the patient with tinnitus?

Play soft background music

A client who is a carpenter reports increasing difficulty holding the tools needed to perform the carpentry skills. Assessment findings reveal carpel tunnel syndrome. The client states, "I must return to work tomorrow. I can't get behind on my schedule." Considering the client's statements, the nurse concludes that what is the issue of most concern?

Potential for injury

A nurse is supervising the care of a patient with multiple sclerosis by an unlicensed assistive personnel (UAP). Which action by the UAP would prompt the nurse to intervene immediately?

Preparing to place the patient in a bathtub with hot water

A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the physical exertion of crutch walking?

Profuse diaphoresis and rapid respirations

A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia?

Prolonged reperfusion of the toes after blanching

After an amputation, a client's residual link is bandaged snugly throughout the postoperative period. What does the nurse teach the client that the primary purpose of the rigid bandaging of the residual limb?

Promote shrinkage of the distal end of the residual limb

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? Select all that apply.

Psychotic behaviorsJacksonian seizuresNausea and vomiting

A client falls at home and is brought to the emergency department by family members. The client reports intercostal pain and is confused and disoriented. What is the best way for the nurse to determine whether this behavior is new for hte client?

Question the family members about the client's usual behavior

A nurse is caring for a patient who is being evaluated for a neurologic disorder. The patient is not able to comprehend the written or spoken word. Which term would the nurse use to document this problem?

Receptive aphasia

Acetylsalicylic acid is prescribed for a client with rheumatoid arthritis. The nurse understand what is the major rationale for this treatment?

Reduction of joint inflammation

A nurse is caring for a 6-year-old child who has undergone craniotomy. The parents ask what effect mannitol has. The nurse responds that htis medication is given to achieve what goal?

Relieve cerebral pressure

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. the nurse should take which appropriated action?

Report the finding to the registered nurse (RN)

A patient arrives at the clinic with uncontrolled type 2 diabetes mellitus. The nurse knows this patient is at an increased risk for which condition?

Retinopathy

Which primary complication would the nurse suspect in a patient with diabetes taking trimethoprim sulfamethoxazole (Bactrim)?

Risk for hyperglycemia

The nurse is administering gentamicin sulfate ophthalmic ointment to a client. After instilling the ointment, the nurse reinforces instructions to the client to close the eye and perform which action?

Roll the eyeball in all directions.

A nurse determines that a client exhibits the characteristics gait associated with Parkinson disease. How should the nurse describe this gait when recording on the client's progress report?

Shuffling

A patient has recently been diagnosed with keratoconjunctivitis sicca and a dry mouth. Which immune disorders is likely to be associated with this diagnosis and symptom?

Sjogren's syndrome

The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?

Sjögren syndrome

A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to do what?

Space activities throughout the day

The nurse is caring for a client who is hearing impaired and should take which approach to facilitate communication?

Speak in a normal tone

The nurse is caring for a client with a head injury. The Glasgow Coma Scale score of the client is 9. Which nursing intervention should be performed in the client immediately?

Stabilize cervical spine

A client who has been diagnosed with bipolar disorder has been admitted to the psychiatric unit. The nurse recognizes that providing adequate nutrition during the manic phase may be a challenge. Why would adequate nutritional intake be a challenge?

The client is too busy keeping active to eat.

A nurse who is preparing to care for a newly admitted patient learns that the patient has myopia. The nurse understands this has which effect on the patient's sensory perception?

The patient is unable to see objects at a distance

How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?

The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response?

This behavior is a common response over which the client has very little control

Why would a topical corticosteroid be prescribed for a patient with otitis externa?

To decrease edema and allow for penetration of antibiotic eardrops

In preparation for cataract surgery, the nurse is to administer cyclopentolate eyedrops. The nurse administers the eyedrops knowing that which is the purpose of this medication?

To dilate the pupil of the operative eye

Why would the nurse instruct a patient who was prescribed carbamide peroxide (Debrox) to avoid touching the tip of the dropper?

To inhibit drug contamination

Which ophthalmic conditions can cause a client to have photophobia? Select all that apply.

Chalazion Trachoma Keratoconjunctivitis sicca

After a cerebrovascular accident (also know as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Parietal

A client is scheduled for arthroscopy of the knee in the morning and asks the nurse about the procedure. Which statement by the nurse best describes the procedure?

"It is a direct visualization of the joint to diagnose the extent of your knee injury."

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply

-To avoid activities that require bending over -To take acetaminophen for minor eye discomfort -To place an eye shield on the surgical eye at bedtime -To contact the surgeon if a decrease in visual acuity occurs

A patient has just had cataract surgery. What information should the nurse include in the discharged instructions? Select all that apply

-Wear an eye shield at night on the operative eye -Avoid bending, stooping, coughing, or lifting -Instill prescribed eyedrops into the conjunctival sac.

After cataract surgery a patient complains of sudden sharp pain in the operative eye. What is the most appropriate nursing action?

Call the surgeon

The nurse is evaluating a patient's eyes as it adjusts to seeing objects at various distances. When documenting, how should the nurse identify the test?

Accomodation

A patient who has been blind for the past 10 years is hospitalized with heart failure. What intervention should the nurse include in the plan of care?

All personnel announce themselves when entering and leaving the room

In the postanesthesia care unit after a below-the-knee amputation, a client begins crying after feeling for the affected lower leg. How should the nurse respond?

Allow the client to ventilate feelings of loss.

A patient visits the health care provider to have her vision tested using the Snellen eye chart. What instruction should the nurse provide to the patient?

Cover one eye while testing the other

When a client who had an above-the-knee amputation (AKA) complains of phantom limb sensations, what should the nursing staff do?

Describe the neurological mechanisms in language that the client understands

A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for what?

Difficulty in swallowing

A health care provider prescribes mannitol for a client with a head injury. The nurse concludes that the purpose of the medication is to relieve cerebral edema by doing what?

Drawing fluid from brain cells into the bloodstream

An older client with dementia of the alzheimer's type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-fowler position. What are of the client's body does the nurse determine is at the greatest risk for developing a pressure ulcer?

Sacrum

The nurse is caring for a patient with vertigo. What is the nurse's priority concern when caring for this patient?

Safety

An 8-year -old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?

Say the child's name and touch the child's arm before starting care

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every one to two hours?

Prevent pressure ulcers

While walking in the hall, a hospitalized client has a tonic-clonic seizure. What should the nurse do to protect the client during the seizure?

Protect the client's head from injury

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? Select all that apply.

Psychotic behaviors Jacksonian seizures Nausea and vomiting

Acetylsalicylic acid is prescribed for a client with rheumatoid arthritis. The nurse understands what is the major rationale for this treatment?

Reduction of joint inflammation

A nurse understands that what is the primary purpose for a client to undergo reconstructive surgery?

Restore function and/or appearance -Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia): temporoparietal deterioration causes cognitive deficiencies in speech(aphasia), and comprehension of visual, auditory,, and other sensations (agnosia),

A client exhibits the characteristics gait associated with Parkinson disease. When recording on the client's record, how does the nurse document this gait?

Shuffling

A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? Select all that apply.

Muscle rigidity Blank facial expression

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

Skin pallor

While communicating with a patient, you notice a possible hearing deficit in one ear. Which nursing intervention would be appropriate?

Speak clearly and in a slightly louder voice toward the patient's face

A client is receiving furosemide (Lasix). For which sign of hypokalemia should the nurse monitor the client?

Flabby muscles

On the fourth day after surgery for a fractured hip, a client appears angry and extremely restless and says, "I can't stand this another minute. There's a wrinkle in my sheet, and the water in my pitcher is warm." The client changes position frequently and does not maintain eye contact with the nurse. The best initial interpretation of the client's behavior is that it indicates what?

Increased levels of anxiety

Initially after a brain attack (cerebrovascular accident), a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?

Increasing intracranial pressure

A client with chronic osteomyelitis in the leg is scheduled to have a debridement of the infected bone. What should the nurse include in the postoperative plan of care?

Inform the client that the leg may be immobilized in a cast or splint

While cleaning the garage, a patient splashed a chemical in his eyes. What is the initial action after the chemical burn?

Irrigate the eye with water for 20 minutes.

When answering questions form the family of a client with alzheimer disease the nurse explains what aobut the disease?

It is a slow, relentless deterioration of the mind

The nurse receives medication orders for a patient with open-angle glaucoma. Whcih medication order does the nurse anticipate?

Mannitol, Cyclogyl

When making round, a nurse observes a client who is experiencing a seizure. What should the nurse do?

Move obstacles away from the client

The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next?

Test the drainage form the client's ear with a glucose reagent strip

When assessing the cognitive development of a 9-year-old child, which characteristic indicates inadequate cognitive development?

The child believes there are more blocks when spread out on the floor than in the container

Family members of a client who had a brain attack (CVA) ask why the client cries easily and without provocation. The nurse explains what about the client?

The client has little control over this behavior

A client who has been diagnosed with a bipolar disorder has been admitted to the psychiatric unit. The nurse recognizes that providing adequate nutrition during the manic phase may be a challenge. Why would adequate nutritional intake be a challenge?

The client is too busy keeping active to eat

A three-year-old child is seen in the emergency department after a fall off a swing, and a possible concussion is diagnosed. When using the Glasgow Coma Scale, the nurse should remember what about most Children three years of age?

They may not respond to strangers asking questions

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a brain attack?

Transient ischemic attacks (TIAs)

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply.

Vomiting Anorexia Irritability Decreased level of consciousness