EXAM 2 - MS1
A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse notes that the client has a history of dry eyes. The nurse interprets this information as indicating a problem with which structure? A. lacrimal apparatus B. sclera C. cornea D. pupil
A
A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer? A. "My pain resolves when I have something to eat." B. "The pain begins right after I eat." C. "I know that my father and my grandfather both had ulcers." D. "I seem to have bowel movements more often than I usually do.
A
A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this client? A. The hearing loss will likely resolve with time after the drug is discontinued. B. The client's hearing loss and tinnitus are irreversible at this point. C. The client's tinnitus is likely multifactorial, and not directly related to aspirin use. D. The client's tinnitus will abate as tolerance to aspirin develops.
A
A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A. Esophageal or pyloric obstruction related to scarring B. Uncontrolled proliferation of H. pylori C. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen
A
A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate
A
A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B. Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C. A laparoscopic approach allows for the removal of the entire gallbladder. D. A laparoscopic approach can be performed under conscious sedation.
A
A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo what intervention? A. Laparoscopic cholecystectomy B. Methyl tertiary butyl ether (MTBE) infusion C. Intracorporeal lithotripsy D. Extracorporeal shock wave therapy (ESWL)
A
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding
A
The nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss? A. The sound is heard better in the ear in which hearing is better. B. The sound is heard equally in both ears. C. The sound is heard better in the ear in which hearing is poorer. D. The sound is heard longer in the ear in which hearing is better.
A
An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. A. Avoid drinking alcohol B. Adopt a low-residue diet C. Avoid nonsteroidal anti-inflammatories D. Take calcium gluconate as prescribed E. Prepare for the possibility of surgery
A,C
A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common cause(s) of blindness and visual impairment among adults over the age of 40? Select all that apply. A. Diabetic retinopathy B. Trauma C. Macular degeneration D. Cytomegalovirus E. Glaucoma
A,C,E
A client comes to the ophthalmology clinic for an eye examination. The client tells the nurse that the client often sees floaters in the client's vision. How should the nurse best interpret this subjective assessment finding? A. This is a normal aging process of the eye. B. Glasses will minimize this phenomenon. C. The client may be exhibiting signs of glaucoma. D. This may be a result of weakened ciliary muscles.
A.
A client develops a perforated eardrum. When teaching the client about this condition, the nurse would identify which condition as a most likely cause? A. infection B. otosclerosis C. Meniere disease D. cholesteatoma
A.
A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? A. Explain the location of items using clock cues. B. Explain that each of the items on the tray is clearly separated. C. Describe the location of items from the bottom of the plate to the top. D. Ask the client to describe the location of items before confirming their location.
A.
A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance
A.
A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration
A.
A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client? A. Sit or stand in front of the client when speaking. B. Use exaggerated lip and mouth movements when talking. C. Stand in front of a light or window when speaking. D. Say the client's name loudly before starting to talk.
A.
A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis? A. Increased bilirubin B. Decreased serum cholesterol C. Increased blood urea nitrogen (BUN) D. Decreased serum alkaline phosphatase level
A.
A gerontologic nurse has observed that clients often fail to adhere to their therapeutic regimen. What strategy should the nurse adopt to best assist an older adult in adhering to a therapeutic regimen involving wound care? A. Demonstrate a dressing change and allow the client to practice. B. Provide a detailed pamphlet on a dressing change. C. Verbally instruct how to change a dressing and check for comprehension. D. Delegate the dressing change to a trusted family member.
A.
A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A. High levels of alcohol consumption B. History of bowel obstruction C. History of diverticulitis D. Longstanding psychosocial stress
A.
A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms. B. Client will demonstrate appropriate care of his ileostomy. C. Client will demonstrate appropriate use of standard infection control precautions. D. Client will adhere to recommended guidelines for mobility and activity.
A.
A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? A. Instill the medication in the conjunctival sac. B. Maintain a supine position for 10 minutes after administration. C. Keep the eyes closed for 1 to 2 minutes after administration. D. Apply the medication evenly to the scler
A.
An advanced practice nurse has performed a Rinne test on a new client. During the test, the client reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding? A. The client's hearing is likely normal. B. The client is at risk for tinnitus. C. The client likely has otosclerosis. D. The client likely has sensorineural hearing loss.
A.
Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis
A.
The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? A. Antidiarrheal medications 30 minutes before a meal B. Antiemetics on a PRN basis C. Vitamin B12 injections to prevent pernicious anemia D. Beta adrenergic blockers to reduce bowel motility
A.
The nurse should recognize the greatest risk for the development of blindness in which of the following clients? A. A 58-year-old Caucasian woman with macular degeneration B. A 28-year-old Caucasian man with astigmatism C. A 58-year-old black woman with hyperopia D. A 28-year-old black man with myopia
A.
A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative
ANS: A Rationale: Decompression of the bowel through a nasogastric tube is necessary for all clients with small bowel obstruction
A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemia B. Imbalanced nutrition: Less than body requirements related to impaired absorption C. Anxiety related to bowel obstruction and subsequent hospitalization D. Impaired skin integrity related to bowel obstruction
ANS: A Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention.
A nurse suspects that an older adult client may be experiencing hearing loss. Which finding would support the nurse's suspicion? Select all that apply. A. Dropping of word endings B. Disinterest in conversations C. Social withdrawal D. Domination of conversations E. Quick decision making
ANS: A, B, C, D
A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced nutrition: Less than body requirements related to decreased oral intake B. Risk for infection related to possible rupture of appendix C. Constipation related to decreased bowel motility and decreased fluid intake D. Chronic pain related to appendicitis
ANS: B Rationale: The client with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.
A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa
ANS: C Rationale: Bloody stool is far more common in cases of UC than in Crohn disease. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohn) and clients with UC typically experience severe diarrhea.
A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding? A. "I need to call the doctor if I get nauseated." B. "I need to call the doctor if I have a light morning discharge." C. "I need to call the doctor if I get a scratchy feeling." D. "I need to call the doctor if I see flashing lights."
ANS: D Rationale: Postoperatively, the client who has undergone cataract extraction with intraocular lens implant should report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the ophthalmologist.
A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? A. Left upper chest B. Inguinal region C. Neck or jaw D. Right shoulder
ANS: D Rationale: The client may have biliary colic with excruciating upper-right abdominal pain that radiates to the back or right shoulder.
A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemetics B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of proton pump inhibitors as prescribed
B
A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as prescribed B. Application of heat 15 to 20 minutes each hour C. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area
B
A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response? A. Surgery is delayed until the client can eat a regular diet without vomiting. B. Surgery is delayed until the acute symptoms subside. C. The client requires aggressive nutritional support prior to surgery. D. Time is needed to determine whether a laparoscopic procedure can be used.
B
A client with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the client states: A. "It is important that I see my health care provider for scheduled follow-up appointments while taking this medication." B. "I will take this medication for 2 weeks and then gradually stop taking it." C. "If I lose weight, the dose of the medication may need to be changed." D. "This medication will help dissolve small gallstones made of cholesterol.
B
A nurse is caring for a client with gallstones who has been prescribed ursodeoxycholic acid (UDCA). The client asks how this medicine is going to help his symptoms. The nurse should be aware of what aspect of this drug's pharmacodynamics? A. It inhibits the synthesis of bile. B. It inhibits the synthesis and secretion of cholesterol. C. It inhibits the secretion of bile. D. It inhibits the synthesis and secretion of amylase.
B
The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? A. Contact the care provider to have the client's hemoglobin and hematocrit measured. B. Document these expected assessment findings. C. Apply barrier ointment to the stoma as prescribed. D. Cleanse the stoma with alcohol or chlorhexidine.
B
The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? A. Pain and peritonitis B. Bleeding and perforation C. Acidosis and hypoglycemia D. Gangrene of the gallbladder and hyperglycemia
B
The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcers B. Aspiration C. Abdominal distention D. Diarrhea
B
The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? A. Performing 15 minutes of physical activity at least three times per week B. Avoiding taking aspirin to treat pain or fever C. Taking multivitamins as prescribed and eating organic foods whenever possible D. Maintaining a healthy body weight
B
An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic medications B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction
B, D
2. An 82-year-old client has come to the clinic for a scheduled follow-up appointment. The nurse learns from the client's child that the client is not following the instructions the client received upon discharge from the hospital last month. What is the most likely factor causing the client not to adhere to the therapeutic regimen? A. Ethnic background of health care provider B. Costs of the prescribed regimen C. Presence of a learning disability D. Personality of the primary provider
B.
A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that eagerness to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond? A. "You have a great attitude. This will likely shorten the amount of time that you need medications." B. "In fact, glaucoma usually requires lifelong treatment with medications." C. "Most people are treated until their intraocular pressure goes below 50 mm Hg." D. "You can likely expect a minimum of 6 months of treatment."
B.
A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When providing relevant health education for this client, the nurse should ensure the client is aware of what potential outcome? A. Bowel incontinence B. Drug-drug interactions C. Abdominal pain D. Heat intolerance
B.
A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client? A. Generously flush the affected eye with a dilute antibiotic solution. B. Generously flush the affected eye with normal saline or water. C. Apply a patch to the affected eye. D. Apply direct pressure to the affected eye.
B.
A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly. B. The client has a rigid, "board-like" abdomen that is tender. C. The client is experiencing intense lower right quadrant pain. D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes.
B.
A hospitalized client with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the client's room? A. That a commode is always available at the bedside B. That all furniture remains in the same position C. That visitors do not leave items on the bedside table D. That the client's slippers stay under the bed
B.
A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. Most affected clients acquired the infection during international travel. B. Infection typically occurs due to ingestion of contaminated food and water. C. Many people possess genetic factors causing a predisposition to H. pylori infection. D. The H. pylori microorganism is endemic in warm, moist climates.
B.
A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? A. Inflammation of the lining of the stomach B. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomach D. Viral invasion of the stomach wall
B.
An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake. C. Assess the client's surgical history. D. Encourage the client to take fiber supplements.
B.
During discharge teaching the nurse realizes that the client is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene? A. Ask the social worker to investigate alternative housing arrangements. B. Ask the social worker to investigate community support agencies. C. Encourage the client to explore surgical corrections for the vision problem. D. Arrange for referral to a rehabilitation facility for vision training.
B.
The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight loss B. Foul-smelling diarrhea that contains fat C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence
B.
The nurse is providing health education to a client diagnosed with glaucoma. The nurse teaches the client that this disease has a familial tendency. The nurse knows that clinical examinations for family members at risk for glaucoma should occur how often? A. At least monthly B. At least once every 2 years C. At least once every 5 years D. At least once every 10 years
B.
The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? A. Potassium-sparing diuretics B. Cholinergics C. Antibiotics D. Loop diuretics
B. Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork.
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A. Administer a Fleet enema as prescribed and remain with the client. B. Contact the primary care provider promptly and report these signs of perforation. C. Position the client supine and insert an NG tube. D. Page the primary provider and report that the client may be obstructed.
B. Rationale: The client's change in status is suggestive of perforation, which is a surgical emergency.
A client has become legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate? A. Encourage the client to focus on use of other senses. B. Assess and promote the client's coping skills during interactions with the client. C. Emphasize that lifestyle will be unchanged once adaptation to vision loss has occurred. D. Promote the client's hope for recovery.
B. The nurse should empathically promote the client's coping with her loss.
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit? A. Recent completion of radiation therapy for treatment of thyroid cancer B. Routine use of quinine for management of leg cramps C. Allergy to hair coloring and hair spray D. Previous perforation of the eardrum
B. Rationale: Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing acuity.
A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? A. Management of fluid balance in the home setting B. The need for blood glucose monitoring for the next week C. Signs and symptoms of intra-abdominal complications D. Appropriate use of prescribed pancreatic enzymes
C
A client is receiving education about an upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that the client may experience which of the following adverse effects associated with this procedure? A. Persistent feelings of hunger and thirst B. Constipation or bowel incontinence C. Diarrhea and feelings of fullness D. Gastric reflux and belching
C
A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider? A. Decreased breath sounds B. Drainage of bile-colored fluid onto the abdominal dressing C. Rigidity of the abdomen D. Acute pain with movement
C
A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? A. Insert a nasogastric tube promptly. B. Reposition the client supine. C. Monitor the client closely for further signs of dumping syndrome. D. Assess the client for signs and symptoms of aspiration.
C
A client who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. What should the nurse include in the client's immediate postoperative plan of care? A. Teaching the client to self-suction B. Performing chest physiotherapy to promote oxygenation C. Positioning the client to prevent gastric reflux D. Providing a regular diet as tolerated
C
A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer? A. Promotion of a nutrient-dense, low-fat diet B. Annual screening endoscopy for clients over 50 with a family history of esophageal cancer C. Early diagnosis and treatment of gastroesophageal reflux disease D. Adequate fluid intake and avoidance of spicy foods
C
A nurse is preparing to discharge a client after recovery from gastric surgery. What is an appropriate discharge outcome for this client? A. Bowel movements maintain a loose consistency. B. Three large meals per day are tolerated. C. Weight is maintained or gained. D. High calcium diet is consumed.
C
A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptying C. It protects the stomach's lining D. It increases lower esophageal sphincter pressure
C
A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. High-fiber foods B. Low-purine, nutrient-dense foods C. Low-fat foods high in proteins and carbohydrates D. Foods that are low-residue and low in fat
C
A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis. B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods. D. Resist the urge to defecate until the urge becomes intense.
C
The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care? A. Risk for disturbed sensory perception B. Risk for unilateral neglect C. Risk for falls D. Risk for ineffective health maintenance
C
A client has been diagnosed with hearing loss related to damage of the cochlea. What term is used to describe this condition? A. Exostoses B. Otalgia C. Sensorineural hearing loss D. Presbycusis
C.
A client has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this client's health status? A. For some clients, these recurrent infections constitute an age-related physiologic change. B. The client would benefit from a temporary mobility restriction to facilitate healing. C. The client needs to be assessed for nasopharyngeal cancer. D. Blood cultures should be drawn to rule out a systemic infection.
C.
A client has informed the home health nurse that he/she has recently noticed distortions when looking at the Amsler grid that is mounted on the refrigerator. What is the nurse's most appropriate action? A. Reassure the client that this is an age-related change in vision. B. Arrange for the client to have his/her visual acuity assessed. C. Arrange for the client to be assessed for macular degeneration. D. Facilitate tonometry testing.
C.
A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem? A. Adherence to a high-fiber diet will help the polyps resolve. B. The client should be assured that this is a normal, age-related physiologic change. C. The client's polyps constitute a risk factor for cancer. D. The presence of polyps is associated with an increased risk of bowel obstruction.
C.
A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis.
C.
A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge? A. The family's ability to take care of the client's special diet needs B. The family's ability to monitor the client's changing health status C. The family's ability to provide emotional support D. The family's ability to manage the client's medication regimen
C.
A nurse is providing anticipatory guidance to a client who is preparing for a total gastrectomy. The nurse learns that the client is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the client's anxiety? A. Emphasize the fact that gastric surgery has a low risk of complications. B. Encourage the client to focus on the benefits of the surgery. C. Facilitate the client's contact with support services. D. Obtain an order for a PRN benzodiazepine.
C.
An older adult client has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the client for recent changes in visual acuity, the client states that the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response? A. Ask if the client has been using OTC vasoconstrictors. B. Instruct the client to repeat the test at different times of the day when at home. C. Arrange for the client to visit an ophthalmologist . D. Encourage the client to adhere to prescribed drug regimen.
C.
The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma? A. The client uses over-the-counter NSAIDs. B. The client has a history of stroke. C. The client has diabetes. D. The client has Asian ancestry.
C.
A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance
D
A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipation C. The risk of fecal incontinence D. The risk of becoming laxative-dependent
D
A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the client at this time? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support
D
A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? A. Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B. Eyeglasses or magnifying lenses C. Corticosteroid eye drops D. Surgical intervention
D
A client presents to the emergency department (ED) reporting severe right upper quadrant pain. The client states that the family doctor said the pain was caused by gallstones. The ED nurse should recognize what possible complication of gallstones? A. Acute pancreatitis B. Atrophy of the gallbladder C. Gallbladder cancer D. Gangrene of the gallbladder
D
A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery? A. Diabetic coma B. Decubitus ulcer C. Wound evisceration D. Bile duct injury
D
A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A. "Drinking beverages after your meal, rather than with your meal, may bring some relief." B. "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." C. "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating." D. "Instead of eating three meals a day, try eating smaller amounts more often."
D
A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? A. Take the medication on an empty stomach. B. Take up to one extra dose per day if stomach pain persists. C. Take at bedtime to mitigate the effects of drowsiness. D. Avoid drinking alcohol while taking the drug.
D
A nurse is assessing an older adult client with gallstones. The nurse is aware that the client may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly client may include what examples? A. Fever and pain B. Chills and jaundice C. Nausea and vomiting D. Signs and symptoms of septic shock
D
A 20-year-old client newly diagnosed with type 1 diabetes needs to learn how to self-administer insulin. When planning the appropriate educational interventions and considering variables that will affect the client's learning, the nurse should prioritize what factor? A. Client's expected lifespan B. Client's gender C. Client's occupation D. Client's culture
D.
A client with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the client administers the pilocarpine, the client states that the client's vision is blurred. Which nursing action is most appropriate? A. Holding the next dose and notifying the health care provider B. Treating the client for an allergic reaction C. Suggesting that the client put on her glasses D. Explaining that this is an expected adverse effect
D.
A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube) B. Gastrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distension D. Administration of injections of vitamin B12
D.
A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Strategies for maintaining an alkaline gastric environment B. Safe technique for self-suctioning C. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages
D.
A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? A. Place the client in a prone position. B. Provide the client with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube. D. Notify the health care provider.
D.
Following a motorcycle accident, an adolescent client is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A. The malleus can be visualized during otoscopic examination. B. The tympanic membrane is pearly gray. C. Tenderness is reported by the client when the mastoid area is palpated. D. Clear, watery fluid is draining from the client's ear.
D.
Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A. Arrange for the administration of prophylactic antibiotics to unaffected residents. B. Instill normal saline into the eyes of affected residents two to three times daily. C. Swab the conjunctiva of unaffected residents for culture and sensitivity testing. D. Isolate affected residents from residents who have not developed conjunctivitis.
D.
The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye? A. 30 seconds B. 1 minute C. 3 minutes D. 5 minutes
D.
The nurse is planning to teach a 75-year-old client with coronary artery disease about administering the prescribed antiplatelet medication. How can the nurse best enhance the client's ability to learn? A. Provide links to websites that contain evidence-based information. B. Exclude family members from the session to prevent distraction. C. Use color-coded materials that are succinct and engaging. D. Make the information directly relevant to the client's condition.
D.
The registered nurse taking shift report learns that an assigned client is blind. How should the nurse best communicate with this client? A. The nurse should provide instructions in simple, clear terms. B. Using a loud voice, the nurse should offer an introduction while in the doorway of the room. C. Lightly touch the client's arm and then say the nurse's name . D. The nurse should state the nurse's name and role immediately after entering the client's room.
D.
Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A. Ensure that clients understand the differences between sensory hearing loss and conductive hearing loss. B. Educate clients about expected age-related changes in hearing perception. C. Educate clients about the risks associated with prolonged exposure to environmental noise. D. Be aware of clients' medication regimens and collaborate with other professionals accordingly.
D.
A nurse is assisting the ophthalmologist who is performing direct ophthalmoscopy. When conducting this examination, which structure would the nurse expect to be examined last? A. red reflex B. vasculature C. optic disc D. macula
D. Rationale: The last area of the fundus to be examined is the macula, because this area is the most sensitive to light
