CM exam 10

A patient who was recently diagnosed with tinnitus asks the nurse about ways to manage ringing. Which of the following are correct? SATA A. Background sound, noise makers and music B. Weekly concerts C. Pramipexole D. Operating heavy machinery

A. Background sound, noise makers and music C. Pramipexole

What will a client report with the sensation of a foreign body? (SATA) A. Blurry vision B. Pain C. Tearing D. Photophobia E. Tickling

A. Blurry vision B. Pain C. Tearing D. Photophobia

What test is the most reliable method for determining hearing loss? A. Otoscopic B. Tuning fork C. Audiometry D. MRI

C. Audiometry

A patient comes to the clinic complaining of poor vision when seeing close objects. The nurse would understand that A. Myopia - With concave lens to correct B. Myopia - With convex lens to correct C. Hyperopia - With a convex lens to correct D. Hyperopia - With a concave lens to correc

C. Hyperopia - With a convex lens to correct

What is the primary care for vision loss in glaucoma A. Retinal detachment B. Macular degeneration C. Optic nerve damage D. Cataract formation

C. Optic nerve damage

The nurse is teaching a group of older adults about basic eye examinations. What would the nurse recommend about the frequency for eye examinations for most people over 65 years of age? a. Every 1 to 2 years b. Every 2 to 4 years c. Every 3 to 5 years d. When the primary health care provider recommends

ANS: A Older adults need more frequent basic eye examinations due to the increased risk of glaucoma and cataracts associated with aging. Therefore, every 1 to 2 years for eye examination in the current best practice recommendation.

A nurse assesses an older adult client with the skin disorder shown below: How will the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas

ANS: A Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paper-thin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action would the nurse take? a. Request a prescription for permethrin. b. Administer an antihistamine. c. Assess the client's airway. d. Apply gloves to minimize friction.

ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin. The nurse would contact the primary care provider to request a prescription for one of the medications. Secondary interventions may include medication to decrease the itching. The client's airway is not at risk with this skin disorder. Applying gloves will help prevent transmission

A client comes in with reduced visual sensory perception. What visual examination would the nurse perform for indication of a cataract? A. Auscultation B. Snellen chart with use of ophthalmoscope C. Use of otoscope D. Rinne test

B. Snellen chart with use of ophthalmoscope

What is a common method to prevent external otitis? A. Using a hair dryer to dry ears B. Wearing earplugs while swimming C. Taking oral antibiotics prophylactically D. Using antifungal ear drops regularly

B. Wearing earplugs while swimming

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A. Provide emotional support B. Educate family on care of child C. Schedule surgery D. Administer prescribed analgesic

D. Administer prescribed analgesic

A client asks about dietary changes that are important for eye health? A. Fried chicken + mac and cheese B. Protein drinks C. Diet rich in fats + protein D. Diet rich in fruit, red, orange, and dark green vegetables

D. Diet rich in fruit, red, orange, and dark green vegetables

An elderly patients presents at his physician office ℅ not being able to hear as well, feels dizzy, with ear pain. The nurse finds copious amounts of hardened ear wax. What action should the nurse take first? A. Ask the patient if he also has ringing in his eras B. Attempt to remove ear wax with forceps C. Flush the patient ear with warm water D. Use medication, (such as cerumenex or debrox) to soften the wax prior to removal

D. Use medication, (such as cerumenex or debrox) to soften the wax prior to removal

Which of the following is not an early symptom of acoustic neuroma? A. Ear pain B. Ringing in the ear (tinnitus) C. Slowly progressing hearing loss in one ear D. Weakness or numbness in face

A. Ear pain

When teaching a patient about signs and symptoms of Meniere's disease. What does the nurse include? SATA A. Episodic vertigo B. Tinnitus C. Hearing loss D. Low heart rate E. Low blood pressure

A. Episodic vertigo B. Tinnitus C. Hearing loss

Which statement by the patient indicates understanding? A. I should expect a green spot on my eye from the fluorescein stain B. The fluorescein stain will heal my eye C. My eye will be stained black D. I can keep my contacts in while stain is applied

A. I should expect a green spot on my eye from the fluorescein stain

A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon. b. Stage 2: may have visible adipose tissue and slough. c. Stage 3: may have a pink or red wound bed. d. Stage 4: wound bed is obscured with eschar or slough.

ANS: A A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An unstageable wound is obscured by eschar or slough making assessment impossible.

A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the size of a nickel, flat, and darker in color than the rest of the client's skin. What does the nurse tell the client regarding these lesions? a. "Monitor these spots for any changes." b. "You don't need to worry about these." c. "I will ask for a dermatology referral for you." d. "We need to schedule you for a skin biopsy."

ANS: A Because of melanocyte hyperplasia, the older adult frequently has "age spots," or darker spots on the skin. The nurse would teach the client to monitor the spots and report any changes indicative of cancer. Stating the client does not need to worry is inaccurate and dismissive. The client does not necessarily need a dermatology referral and does not need a skin biopsy at this point.

The nurse reads on a chart that a client has lichenification. What assessment finding confirms this description? a. Increased skin thickness b. Excessive facial hair c. Purple skin patches d. Tightly stretched skin

ANS: A Lichenification is increased skin thickness as the result of scarring. Excessive facial hair (or body hair) is hirsutism. Purple patches on the skin are purpura. Tightly stretched skin is from edema.

A client has multiple lesions all over the body and a family history of skin cancer. The nurse teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient's teaching? (Select all that apply.) a. "Look for asymmetry of shape and irregular borders." b. "Assess for color variation within each lesion." c. "Examine the distribution of lesions over a section of the body." d. "Monitor for edema or swelling of tissues." e. "Focus your assessment on skin areas that itch." f. "Report any lesions that change over time in any way."

ANS: A, B, F Patients will be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

A nurse plans care for a client who has a wound that is not healing. Which focused assessments will the nurse complete to develop the patient's plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results f. Weight

ANS: A, C, D, ......E?? F Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status will include a high-protein, high-calorie diet. To determine the patient's nutritional status, the nurse will assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and body mass. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing

A nurse is working with a client who has a painful rash consisting of grouped weeping and crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all that apply.) a. Instruct the client to report lesions near the eyes. b. Have the client take long, hot baths to soak the lesions. c. Show the client how to make a baking soda compress. d. Advise the client to avoid exposure to UV light rays. e. Demonstrate proper use of antifungal medications. f. Review appropriate hygiene measures.

ANS: A, C? D This client has herpes zoster (shingles). Eye infection is possible, so the client should be taught to report any lesions erupting near the eyes. Comfort measures can include compresses, calamine lotions, and baking soda. Long hot baths are not recommended. Avoiding UV lighting is important for herpes simplex. Herpes zoster is a viral disorder, so antifungal medications are not used. Hygiene is not an issue causing an outbreak.

A nurse evaluates the following data in a client's chart: Admission Note: A 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis Laboratory Results: White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL (152 mg/L) Albumin: 4.2 mg/dL (42 mg/L) Lymphocyte count: 2000/mm3 (2 X109/L) Wound Care Note Sacral ulcer: 4X 2 X 1.5cm Based on this information, which action would the nurse take? a. Perform a neuromuscular assessment. b. Request a dietary consult. c. Initiate Contact Precautions. d. Assess the client's vital signs.

ANS: B The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse would request a dietary consult. The other interventions do not address the information provided.

A nurse is teaching a client who has itchy, raised red patches covered with a silvery white scale how to care for this disorder. What statement by the client shows a need for further information? a. "At the next family reunion, I'm going to ask my relatives if they have anything similar." b. "I have to make sure I keep my lesions covered, so I do not spread this to others." c. "I must avoid large crowds and sick people while I am taking adalimumab." d. "I will buy a good quality emollient to put on my skin each day."

ANS: B This client has plaque psoriasis which is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links so it would be correct for the client to inquire about other family members who are affects. Adalimumab is a drug used to treat psoriasis and it has a black box warning about serious infection risk and cancer risk, so the client needs to take precautions to avoid infectious individuals. Emollients help keep the plaques soft and reduce itching

What are the signs and symptoms of mastoiditis? SATA A. Swelling behind ear B. Pain is not relieved by myringotomy C. Hearing loss D. Lymph nodes behind ears are tender E. Low grade fever

A. Swelling behind ear B. Pain is not relieved by myringotomy C. Hearing loss D. Lymph nodes behind ears are tender E. Low grade fever

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

ANS: A Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

A nurse assesses a client who has open skin lesions. Which action by the nurse is most important? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the client's pain. d. Obtain vital signs.

ANS: A Nurses wear gloves as part of Standard Precautions when examining skin that is not intact. The other options are part of the full assessment but adhering to Standard Precautions is important for safety and infection control.

A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which question will the nurse ask to elicit useful information about the possible condition? a. "What do you do for a living?" b. "Are your nails professionally manicured?" c. "Do you have diabetes mellitus?" d. "Have you had a recent fungal infection?"

ANS: A The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.

The nurse enters an examination room to help with an eye assessment. The client is directed toward the chart shown below: 'Circle with multicolored dots varrying in color to form a number in teh middle' What is the primary health care provider assessing? a. Color vision b. Depth perception c. Spatial perception d. Visual acuity

ANS: A This is an Ishihara chart, which is used for assessing color vision. Depth and spatial perception are not typically assessed in a routine vision assessment. Visual acuity is usually tested with a Snellen chart.

A client has a foreign body in one eye. What action by the nurse is appropriate for the client's care? a. Administering ordered antibiotics b. Assessing the patient's visual acuity c. Obtaining consent for enucleation d. Removing the object immediately

ANS: A To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client's airway. b. Irrigate the client's skin c . Brush any visible dust off the skin. d. Call poison control for guidance

ANS: A With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called.

The nurse is assessing a client admitted to the emergency department with possible retinal detachment. What assessment findings would the nurse expect? (Select all that apply.) a. Presence of bright light flashes b. Decreased visual field in affected eye c. Feeling like a curtain is over one eye d. Gradual changes in visual acuity e. Painful throbbing in the affected eye

ANS: A, B, C Changes that occur in clients experiencing retinal detachment are usually sudden and painless. Typical changes that occur include bright light flashes, sudden decrease in visual filed, and a feeling like a curtain is over all or part of the affected eye.

The nurse is teaching a client about care after surgery to repair a retinal detachment. What health teaching would the nurse include? (Select all that apply.) a. "Report sudden pain in the surgical eye." b. "Report if the surgical eye remains dilated." c. "Avoid close vision activities in the first week." d. "Avoid activities that increase intraocular pressure." e. "Report sudden reduced visual acuity."

ANS: A, B, C, D, E All of these instructions are important for the client who has a retinal detachment repair

The nurse is teaching a client and family regarding symptoms to report to the primary health care provider after cataract surgery. Which symptoms would the nurse include in the teaching? (Select all that apply.) a. Sharp sudden pain in the surgical eye b. Green or yellow discharge from the surgical eye c. Eyelid swelling of the surgical eye d. Decreased vision in the surgical eye e. Blindness in the surgical eye f. Flashes or floaters seen in the surgical eye

ANS: A, B, C, D, E, F All of these symptoms are not normal and should be reported immediately to the surgeon or other appropriate primary health care provider.

The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) a. Thinner skin b. Slower healing time c. Decreased mobility d. Hyperresponsive immune response e. Increased risk of unnoticed sepsis f. Pre-existing conditions

ANS: A, B, C, E, F Age-related differences that can increase the risk of burns and complications of burns include thinner skin, slower healing, decreased mobility, increased risk of infection that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses.

The nurse is teaching a client about postoperative care after a LASIK procedure. Which common complications/adverse effects could occur either immediately or later after this type of surgery? (Select all that apply.) a. Halos around lights b. Blurred vision c. Blindness d. Infection e. Dry eyes

ANS: A, B, D, E All of these common problems can occur after LASIK surgery except for blindness. Some decrease in visual acuity can occur, however

The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

ANS: A, B, D, E Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

A nurse cares for many clients with pressure injuries. What actions by the nurse are considered best practice? (Select all that apply.) a. Conduct ongoing assessments that include pain. b. Use normal saline to cleanse around the pressure injury. c. Soak eschar daily until it softens and can be removed. d. Consult with a registered dietitian nutritionist. e. Use antimicrobial agents to clean wounds that are infected. f. Consider the use of adjuvant therapies for nonhealing wounds.

ANS: A, B, D, E, F Best practice for pressure injury wound management includes ongoing assessments that include pain, using normal saline to clean gently around the wound, ensuring optimal nutrition by involving a registered dietitian nutritionist, using an antimicrobial agent to clean wounds that are anticipated to become infected, and considering the use of adjuvant therapies such as stimulation, negative-pressure wound therapy, ultrasound, hyperbaric oxygen, and topical growth factors. The nurse would not disturb stable eschar

The nurse in the emergency department would arrange to transfer which burned clients to a burn center? (Select all that apply.) a. 15% partial-thickness burn b. Lightening injury c. 7% partial-thickness burn d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum

ANS: A, B, D, E, F Clients with major burns are transferred to a burn center for specialized care. These include any partial-thickness burn over 10% TBSA; any lightening injury; a burn injury in a client with a history of pre-existing conditions that could complicate care or prolong recovery; adults over the age of 60; and burns to the face, hands, feet, genitalia, perineum, or major joints. The client with a 7% partial-thickness burn could be cared for in a hospital or a burn center

A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which nonpharmacologic comfort measures would the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with colloidal oatmeal e. Back rub with baby oil

ANS: A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse would implement cool, moist compresses and tepid baths with additives such as colloidal oatmeal. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

A nurse plans care for a client who is immobile. Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the client's heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they would be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients would be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore

The nurse is teaching a group of adults about ways to prevent early cataract formation. What health teaching would the nurse include? (Select all that apply.) a. "Wear eye and head protection when playing sports." b. "Be sure to get 7 to 8 hours of sleep each night." c. "Drink less carbonated beverages, especially those with caffeine." d. "Wear sunglasses when going outdoors or in ultraviolet light." e. "Increase consumption of high-protein, low-carbohydrate foods." f. "Avoid smoking or participate in a smoking cessation program."

ANS: A, D, F Although all of these choices are strategies for overall health promotion. Wearing eye and head protection and sunglasses, and avoiding or quitting smoking are specific strategies to promote eye health. Cataracts may occur earlier in a client's life if these recommendations are not followed.

A nurse assesses a client who presents with early koilonychias. Which assessments will the nurse complete next? (Select all that apply.) a. Review the client's health history for a diagnosis of iron deficiency anemia. b. Palpate the client's nail base for potential edemata and sponginess. c. Ask the client about prolonged contact with chemical irritants. d. Assess the client for signs of chronic obstructive pulmonary disease. e. Request a prescription to assess the client's hemoglobin A1C.

ANS: A, E Early koilonychias manifests as flattening of the nail plate with an increased smoothness of the nail. This is caused by iron deficiency with or without anemia, poorly controlled diabetes, and local injury. Nails with visible edema and sponginess when palpated are associated with clubbing. Chronic obstructive pulmonary disease may cause clubbing of the nails and chemical irritants are associated with late koilonychias.

A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers

ANS: B As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.

While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action will the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the patient's oxygen saturation. c. Auscultate the patient's lung fields for adventitious sounds. d. Palpate the patient's bilateral radial and pedal pulses.

ANS: B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse will assess for systemic oxygenation before continuing with other assessments.

A nurse evaluates the following data in a client's chart: Admission Note: A 78 y/o male w/ past medical history of atrial fib. is admitted w/ chronic leg wound Prescriptions: Warfarin, Sotalol Wound Care: Negative-pressure wound therapy to leg wound Based on this information, which action would the nurse take first? a. Assess the client's vital signs and initiate continuous telemetry monitoring. b. Contact the primary health care provider to discuss the treatment c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements

ANS: B A client on anticoagulants is not a candidate for NPWT because of the incidence of bleeding complications. The health care primary health care provider needs this information quickly to plan other therapy for the client's wound. The nurse would contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring are appropriate for a client who has a history of atrial fibrillation and would be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring.

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? a. Requests a referral to a registered dietitian nutritionist. b. Raises the head of the bed no more than 45 degrees. c. Performs perineal cleansing every 2 hours. d. Assesses the client's entire skin surface daily.

ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. The nurse needs to keep the head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN consultation, frequent perineal cleaning, and assessing the client's entire skin surface are all appropriate actions

A client had a retinal detachment and has undergone surgical correction. What discharge health teaching is most important for the nurse to include? a. "Avoid reading, writing, or close work such as sewing." b. "Report immediate loss of vision of pain in the affected eye." c. "Keep the follow-up appointment with the ophthalmologist." d. "Remove your eye patch every hour for eyedrops."

ANS: B After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because these activities cause rapid eye movements. However, more importantly is the need for the client or family to report loss of vision or pain in the surgical eye. Keeping a postoperative appointment is important for any surgical patient. The eye patch is not removed for eyedrops after retinal detachment repair.

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure that the client has a patent airway. c. Prepare to irrigate the client's eye. d. Turn the client on the unaffected side.

ANS: B Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client's eye may or may not be irrigated.

A client has been prescribed brinzolamide for glaucoma. What assessment by the nurse requires communication with the primary health care provider? a. Allergy to eggs b. Allergy to sulfonamides c. Use of contact lenses d. Use of beta blockers

ANS: B Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

A nurse assesses a client who has psoriasis. Which action would the nurse take first? a. Don gloves and an isolation gown. b. Shake the client's hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse would first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy would be completed after establishing a report with the client.

A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? a. "Dermabrasion or chemical peels can be done in the office." b. "I may need lymph node resection during Mohs surgery." c. "This needs only a small excision with local anesthetic." d. "After surgery I will need 8 weeks of radiation therapy."

ANS: B Melanoma is usually treated with Mohs micrographic surgery, in which tissue is sectioned horizontally in layers and examined histologically, layer by layer, to assess for cancer cells. Dermabrasion and chemical peels can be used on actinic keratoses. Local anesthetic for small excisions is generally used on basal or squamous cell carcinomas. Radiation is usually not used with melanoma

A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel

ANS: B Pale conjunctivae signify anemia. The nurse will assess the client's hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client's potential anemia

After teaching a client who has a stage 2 pressure injury, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Green salad, a banana, whole wheat dinner roll, coffee b. Chicken breast, broccoli, baked potato, ice water c. Vegetable lasagna and green salad, iced tea d. Hamburger, fruit cup, cookie, diet pop

ANS: B Successful healing of pressure injuries depends on adequate intake of calories, protein, vitamins, minerals, and water. The dinner with the chicken breast meets all these criteria. The other dinners while having some healthy items each, are not as nutritious

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands. b. Irregular mole with multiple colors on the leg. c. Large cluster of pustules in the right axilla. d. Thick, reddened papules covered by white scales

ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Freckles are a benign condition. Pustules could mean an infection, but it is more important to assess the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection? a. WBC 9200 mm/L3 (9.2 109 ) b. Boggy feel to granulation tissue c. Increased size after debridement d. Requesting pain medication

ANS: B Wound infection may or may not occur in the presence of signs of systemic infection, but a change in the appearance, texture, color, drainage, or size of a wound (except after debridement) is indicative of possible infection. The nurse would assess the client with boggy granulation tissue further. The WBC is normal. After debridement, the wound may look larger. If the client needs a sudden increase in the amount or frequency of pain medication that would be another indicator, but there is no evidence this client has more pain than usual.

The nurse is teaching a client about preventing intraocular pressure increase after cataract surgery. Which health teaching would the nurse include? (Select all that apply.) a. "Don't lift objects weighing more than 20 lb (9.1 kg)." b. "Avoid blowing your nose or sneezing." c. "Don't bend down from the waist." d. "Don't strain to have a bowel movement." e. "Avoid having sexual intercourse." f. "Don't wear tight shirt or blouse collars."

ANS: B, C, D, E, F All of these precautions can help prevent an increase in intraocular pressure except that the client should not lift anything weighing more than 10 lb (4.5 kg).

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you recently used a public shower?" d. "Have you been out of the country recently?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

ANS: B, E, F Outbreaks of psoriasis can be induced by stress, environmental triggers, certain medications, skin injuries, infections, smoking, alcohol use, and obesity. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

During skin inspection, the nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors will the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed

ANS: C "Diffuse" is used to describe lesions that are widespread. "Serpiginous" describes lesions with wavy borders. "Clustered" describes lesions grouped together. "Linear" describes lesions occurring in a straight line. Annular lesions are ring like with raised borders, circinate lesions are circular, and circumscribed lesions have well-defined sharp borders. "Coalesced" describes lesions that merge with one another and appear confluent.

The nurse is teaching a client about cataract surgery. Which statement would the nurse include as part of preoperative preparation? a. "You will receive general anesthesia for the surgical procedure." b. "You will be in the hospital for only 1 to 2 days if everything goes as expected." c. "You will need to put several types of eyedrops in your eyes before and after surgery." d. "You will be on bedrest for about a week after the surgical procedure."

ANS: C Cataract surgery is done as an ambulatory care procedure and the client is not hospitalized, does not receive general anesthesia, and does not need to be on bedrest postoperatively.

A nurse cares for an older adult client who has a chronic skin disorder. The client states, "I have not been to church in several weeks because of the discoloration of my skin." How will the nurse respond? a. "I will consult the chaplain to provide you with spiritual support." b. "You do not need to go to church; God is everywhere." c. "Tell me more about your concerns related to your skin." d. "Religious people are nonjudgmental and will accept you."

ANS: C Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses will assess how the client's skin changes are affecting his or her body image and encourage the client to express feelings about a change in appearance. The other statements are dismissive of the client's concerns.

A client with a family history of glaucoma asks the nurse how to prevent glaucoma? What statement by the nurse is appropriate? a. "You should check with your primary health care provider about eye examination." b. "You should have genetic testing to determine your risk for glaucoma." c. "You should have your intraocular pressure measured once or twice a year." d. "You should check with your primary health care provider about preventive drug therapy.

ANS: C Glaucoma tends to occur more often in clients who have a family history but cannot be prevented. Genetic testing is not the best response because the client's family history is already known. Therefore, early detection by having intraocular pressure measured frequently.

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client's understanding. Which statement indicates the client has a good understanding of this condition? a. "This rash is probably due to fluid overload." b. "I need to wash this daily with antibacterial soap." c. "I can use powder to keep this area dry." d. "I will schedule a mammogram as soon as I can."

ANS: C Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury development? a. A 44 year old prescribed IV antibiotics for pneumonia b. A 26 year old who is bedridden with a fractured leg c. A 65 year old with hemiparesis and incontinence d. A 78 year old requiring assistance to ambulate with a walker

ANS: C Risk factors for development of a pressure injury include lack of mobility, exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. The client with hemiparesis and incontinence has two risk factors. The client with pneumonia has no identified risk factors. The other two are at lower risk if they are not very mobile, but having two risk factors is a higher risk

A nurse assesses a young female client who is prescribed tazarotene. Which question should the nurse ask prior to starting this therapy? a. "Do you spend a great deal of time in the sun?" b. "Have you or any family members ever had skin cancer?" c. "Which method of contraception are you using?" d. "Do you drink alcoholic beverages?"

ANS: C Tazarotene has many side effects. It is a known teratogen and can cause severe birth defects. Strict birth control measures must be used during therapy. The other questions are not directly related to this medication

A nurse is teaching a client and family about self-care at home for the client's wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? a. "I will keep dry bandages on the wound and change them when drainage appears."b. "I will shower instead of taking a bath in the bathtub each day." c. "If the dressing is dry, I can sit or sleep anywhere in the house." d. "I will clean exposed household surfaces with a bleach and water mixture."

ANS: C The client should not sit on upholstered furniture or sleep in the same bed as another person until the infection has cleared. The other statements show good understanding.

A client's intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Teach about drugs for glaucoma. d. Refer the patient to local Braille classes.

ANS: C This increased IOP indicates glaucoma. The nurse's main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

A client who is nearly blind is admitted to the hospital. What action by the nurse is most important? a. Allow the client to feel his or her way around. b. Let the client arrange objects on the bedside table. c. Orient the client to the room using a focal point. d. Speak loudly and slowing when talking to the client.

ANS: C Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is appropriate, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate? a. "The wound edges have been approximated and stitched together." b. "The wound was stapled together after an infection was cleared up." c. "The wound is an open cavity that will fill in with granulation tissue." d. "The wound was contaminated by debris and can't be closed at all."

ANS: C Wounds healing by second intention are deeper wounds that leave open cavities. These wounds heal as connective tissue fills in the dead space. A wound that has its edges brought together (approximated) and sutured or stapled together is said to be healing by first intention. A wound that was left open while an infection healed and then is closed is an example of healing by third intention. A wound that cannot be closed at all would be left to heal by second intention.

A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

ANS: D A client with an ulcer on the foot would be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse emphasize as possibly indicating beginning cataract formation? a. Diplopia b. Cloudy pupil c. Loss of peripheral vision d. Blurred vision

ANS: D A cloudy pupil is a sign of late cataracts and loss of peripheral vision is more common in clients who have glaucoma. Diplopia occurs with a number of neurologic diseases. Blurred vision is the earliest sign that the lens of the eye is undergoing changes.

A client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate? a. "Take monthly photographs of it so you can document any changes." b. "Wash daily with warm water and gentle soap to prevent infection." c. "Keep the lesion covered with a bandage and triple antibiotic ointment." d. "Please make an appointment to be seen here as soon as possible."

ANS: D A lesion demonstrating a change in characteristics, such as oozing, crusting, bleeding, or scaling, is suspicious for skin cancer. The nurse would instruct the client to come in for evaluation. Monthly photographs are a good way to document skin changes, but the client needs an assessment for skin cancer. The lesion can be washed and covered with a bandage and ointment, but again, the client needs an evaluation for skin cancer.

The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development? a. Heart disease b. Glaucoma c. Diabetes mellitus d. Advanced age

ANS: D Advanced age is the major risk factor for developing cataracts because the lens loses water and lens fibers become more compact.

A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first? a. Client with intraocular pressure reading of 24 mm Hg b. Client with a tearing, reddened eye with exudate c. Client whose red reflex is absent on ophthalmologic examination d. Client who has had cataract surgery and has worsening vision

ANS: D After cataract surgery, worsening vision indicates a postoperative infection or other complication. The nurse would see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question will the nurse ask first? a. "Are you using lotion on your skin?" b. "Do you have a family history of this?" c. "Do your arms itch?" d. "What medications are you taking?"

ANS: D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

A client is taking timolol eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? a. Ask the client about excessive salivation. b. Take the client's blood pressure and temperature. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the primary health care provider.

ANS: D The nurse would hold the eyedrops and notify the primary health care provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Taking the blood pressure and temperature are not necessary. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? a. Wet-to-damp saline moistened gauze b. None, the wound is left open to the air c. A transparent film d. Multi-fiber superabsorbent dressing

ANS: D This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of necrotic tissue. A draining wound would not be left open. A transparent film is a good choice for a noninfected stage 2 pressure injury.

A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Presence of toenail fungus d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

ANS: D, F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the Skin Cancer Foundation's hallmark signs for cancer according to the ABCDE method. Other signs and symptoms, while not normal, are not cause for concern.

A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information? a. "I will shower daily using a super-fatted soap." b. "I can try taking a bath with colloidal oatmeal." c. "I will pat my skin dry instead of rubbing it with a towel." d. "I will be careful to keep my nails filed smoothly."

ANS: D? Seems like should be A The client with pruritus should shower only every other day, although super-fatted soap is an appropriate choice. Colloidal oatmeal baths are very soothing. Patting the skin dry avoids trauma and injury. Keeping nails filed smoothly also prevents injury

A nurse is planning discharge for a patient with sensorineural hearing loss. Which statement indicates a need for further teaching? A. My diabetes probably contributed to my hearing loss, right? B. My job on the road crew needs to provide me with ear protection C. Very few medications cause toxicity to the inner ear structures D. My dizziness is pretty common with hearing loss

C. Very few medications cause toxicity to the inner ear structures

A nurse is teaching a group of new nurses about macular degeneration. Which statement demonstrates a correct understanding of the teaching? A. Dry MD progresses faster in non-smokers B. Being older than 55 is a risk factor C. Wet MD can occur at any age, in one eye or both D. Treatment for dry MD is carotenoids

C. Wet MD can occur at any age, in one eye or both