Med Surg Ch. 39, 40, 46-48

Respiratory manifestations of anemia

-Dyspnea on exertion -Decreased O2 sat levels

Which test best determines hearing acuity? A. Audioscopy B. Electronystagmography C. Otoscope D. Snellen test

A. Audioscopy involves the use of a handheld device to generate tones of varying intensity to test hearing. Electronystagmography is a test that is sensitive for detecting central and peripheral disease of the vestibular system in the ear. An otoscope is used to inspect the ear canal. The Snellen test is a vision acuity test.

A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? A. Magnetic resonance imaging (MRI) B. Ophthalmoscopy C. Radioisotope scanning D. Snellen chart

A. Because the client has metal in the eye, MRI is an absolute contraindication. Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

The nurse is teaching a client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction? A. "I'll have to wear a bandage over my eye after the test." B. "I will be awake during this test." C. "I won't hear the high-frequency sound waves." D. "This test will help determine whether my retina is detached."

A. No special follow-up care is needed after an ultrasonography of the eye, so the client does not have to wear a bandage after the test. However, the client should be reminded not to rub or touch the eye until the effects of the anesthetic drops have worn off. The test is noninvasive and painless, and the client remains awake during the test. The high-frequency sound waves that are bounced through the eye cannot be heard. Ultrasonography aids in the diagnosis of trauma, intraorbital tumor, proptosis, and choroidal or retinal detachment.

Drugs that cause bone marrow suppression

Altretamine; amphotercin B; azathioprine; chemotherapeutic agents; chloramphenicol; chromic phosphate; colchicine; didanosine; eflornithine; foscarnet sodium; ganciclovir; interferon alfa; pentamidine; sodium iodine; zalcitabine; zidovudine

Arcus senilis (aging eye):

An opaque, bluish white ring within the outer edge of the cornea; caused by fat deposits

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply.) A. "You will need to wear a patch on your eye for several weeks after the surgery." B. "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." C. "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." D. "Bring sunglasses with you on the day of your procedure." E. "You might experience a lot of bruising and swelling around the eye."

B. C. D. The client will have multiple eyedrops to use after surgery and should be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eyedrops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure. A patch is required after surgery only if a risk for injury is present. Cataract surgery does not cause bruising and swelling post-surgery.

Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? (Select all that apply.) A. Anemia B. Diabetes mellitus C. Hepatitis D. Hypertension E. Multiple sclerosis (MS)

B. D. E. Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity. Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

Which eye procedure requires informed consent from the client? A. Eyedrop instillation B. Fluorescein angiography C. Ophthalmoscopy D. Snellen test

B. Fluorescein angiography is an invasive test and requires informed consent from the client. Eyedrop instillation, ophthalmoscopy, and the Snellen test are not invasive procedures and do not require informed consent from the client.

An older adult client reports nausea during removal of impacted cerumen from the ear canal. What does the nurse do next? A. Administer an antiemetic. B. Call the health care provider. C. Stop irrigation immediately. D. Use less water to irrigate.

C. The client's nausea may be a sign of vertigo. If nausea, vomiting, or dizziness develop in the client, irrigation should be stopped immediately. Antiemetics should not be administered immediately in this case. The client's nausea may be a symptom of vertigo, and further assessment is required first. The health care provider should not be notified before further assessment of the client is done by the nurse. Using less water will not alleviate the client's nausea.

A client has a purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first? A. Administer a Snellen test. B. Obtain an informed consent. C. Instill antibiotic drops. D. Put on gloves.

D. Gloves should be worn in the presence of drainage and should be put on before examining the eye. Administering a Snellen test or instilling antibiotic eyedrops is not the first thing that the nurse should do before examining the client's eye. Obtaining informed consent is not necessary for an eye examination.

Astigmatism: distort vision

Refraction error caused by unevenly curved surfaces on or in the eye, especially the cornea

Drugs that disrupt platelet action

aspirin; carbenicilliin; carindacillin; dipyridamole; ibuprofen; meloxicam; naproxen; oxaprozin; pentoxifylline; sulfinpyrazone; ticarcillin; ticopidine; valproic acid

Anemia

reduction in either the number of RBC, the amount of hemoglobin, or hematocrit (% of packed RBC/deciliter)

A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? (Select all that apply.) A. Announce name and purpose when entering the client's room. B. Explain food positions on the tray using a clock face as the example. C. Orient the client to the location of the call light, and keep it in that place. D. Orient the client to the room surroundings and equipment. E. Speak in a loud, clear voice.

A. B. C. D. Staff should always introduce themselves to clients, with or without visual issues. Using a standard clock face to explain food locations on the tray will assist the client with self-feeding. Providing room orientation to the client is important to improve his or her ability for self-care. Orienting the client to the room and equipment in the room will allow him or her to have increased comfort with surroundings. This client has visual issues, not hearing issues, so speaking louder is not necessary.

A client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use? A. Gesturing B. Sign language C. Speaking D. Writing

D. Writing is the most effective way to communicate with the client who has undergone a stapedectomy. Gesturing can be vague and imprecise. Sign language requires training. It is hoped that the client will not be hearing-impaired long enough for this to be a viable option. The client will not be able to hear for the first 6 weeks after surgery.

Skin moisture: skin dryness may indicate any number of hematologic disorders

Normal changes in aging adult: skin dryness is a normal result of aging; skin moisture is not reliable when assessing an older adult

Drugs that cause hemolysis

acetohydroxamic acid; amoxicillin; chlorpropamide; doxapram; glyburide; mefenamic acid; menadiol diphosphate; methyldopa; nitrofurantoin; penicillin G benzathine; penicillin V; primaquine; procainamide hydrochloride; quinine; sulfonamides; tolbutamide; vitamin K

Care of the pt. with SCD -administer O2 -administer prescribed pain medicine -hydrate the pt. w/ normal saline IV and w/ beverages of choice w/o caffeine -remove constrictive clothing -encourage pt. to keep extremities extended to promote venous return

-Do not raise the knee position of the bed -Elevate the head of the bed (no more than 30 degrees) -Keep room @ or above 72 degrees -Avoid taking BP with external cuff -Check circulation every hour (pulse ox of fingers and toes; capillary refill; peripheral pulses; toe temp)

Neurological manifestation of anemia

-Increased somnolence and fatigue -Headache

Integumentary manifestations of anemia

-Pallor, especially of the ears, nail beds, palmer creases, conjunctivae, and around the mouth -Cool to touch -Intolerance of cold temp -Nails become brittle and concave

Cardiovascular manifestations of anemia

-Tachycardia at basal activity levels, increasing with activity and during and immediately following meals -Murmurs and gallops heard of auscultation with severe anemia -Orthostatic hypotension

Prevention of Sickle Cell Crisis -drink at least 3-4 L/day -avoid alcohol and tobacco -contact HCP @ first sign of illness or infection -be sure to get a flu shot every year -ask HCP about pneumonia vaccine -avoid extreme temps -wear socks and gloves on cold days

-avoid planes with unpressurized passenger cabins -avoid traveling to high altitudes (Denver, Santa Fe) - consider genetic counseling -avoid strenuous physical activity -engage in mild, low impact exercise 3x week when not in sickle cell crisis

An older adult client reports ear pain. Otoscopic examination by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? A. Continues further assessment B. Irrigates the ear C. Prescribes antibiotics for probable otitis media D. Tests hearing acuity

A. A dull and retracted membrane should not be the only indication of otitis media for the older adult client. This finding may be a normal age-related change, so further assessment is continued. Irrigating the ear is not indicated for this client. Further assessment is needed to determine whether the client has otitis media; therefore, antibiotics should not be prescribed. Auditory assessment is the last part of an ear examination after the otoscopic examination.

Which clients are at high risk for developing hearing problems? (Select all that apply.) A. Airline mechanic B. Client with Down syndrome C. Drummer in a rock band D. Teenager listening to music using ear buds E. Telephone operator

A. B. C. D. An airline mechanic is exposed to excessive noise and is at risk for hearing damage. A client with Down syndrome is at risk for hearing problems because this genetic condition is associated with frequent hearing problems. A drummer in a rock band is at risk for hearing problems due to exposure to loud noise. A teenager listening to music using ear buds is at high risk because ear buds are known risk factors for increasing potential hearing loss among people who use them on a regular basis with elevated noise levels. A telephone operator is not at risk for hearing problems simply because he or she may wear headphones or audio equipment.

The nurse is performing an otoscopic examination of a client's ear and sees a greenish-white drainage. What does the nurse do next? A. Disposes of the otoscope tip and washes the hands before examining the other ear B. Reports the finding to the health care provider immediately C. Sends a specimen for culture D. Suctions out the drainage

A. Contact Precautions must be used with any client who has drainage from the ear canal. To prevent cross-contamination, the nurse should dispose of the otoscope tip and wash the hands before examining the opposite ear. The health care provider will be notified after the ear examination is complete. After an otoscopic examination, the nurse must perform an auditory assessment. A specimen is obtained only if the nurse is examining the external meatus region, but this is not the first step. The nurse must assess the second ear and compare. Suctioning the ear that is infected causes trauma to the tissue.

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds

A. D. E. Any action that would increase pressure in the eye should be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects. Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.

The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? A. "I always wear earplugs when I swim." B. "It is noisy where I work, so I listen to music with ear buds." C. "My ears ring after attending a rock concert, but it goes away." D. "The machinery is loud at work, but I get used to it."

A. Earplugs worn during swimming protect against potential ear infection. If the client's work environment is noisy, the client will have to turn up the volume significantly of music played through ear buds. A ringing in the ears (tinnitus) may be a sign of injury. Clients should wear earplugs in environments with loud music. Not wearing ear protection around noisy machinery will cause damage to the ear. "Getting used to" the noise is a sign that damage has occurred.

A client has a bilateral corneal disorder and must instill anti-infective eyedrops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? A. "I have two bottles of eyedrops because I will require a lot of medication." B. "I won't be able to wear my contacts for a while." C. "I must apply the drops throughout the night." D. "I must wash my hands before and between eye applications and after putting the drops in."

A. If both eyes are infected, separate bottles of drugs are needed for each eye. The client should be taught to clearly label the bottles "right eye" and "left eye" and to not switch the drugs from eye to eye. The client should not wear contact lenses during the entire time that these drugs are being used because the eye then has fewer protections against infection or injury. In addition, the drugs can cloud or damage contact lenses. If the drugs are to be instilled every hour for the first 24 hours, the client will have to wake up every hour during the night to apply the drops. The client should completely care for one eye, wash the hands, and by using the drugs for the remaining eye, care for that eye. As always, handwashing should be done before and after eye care.

The nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? A. An 18-year-old who had an emergency splenectomy B. A 22-year-old with recently diagnosed sickle cell anemia C. A 38-year-old with hemolytic anemia D. A 40-year-old alcoholic with liver disease

A. Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms, and is at increased risk for infection. Sickle cell anemia causes pain and discomfort because of the changed cell morphology, so acute pain, especially at joints, is the greatest threat to this client. A low red blood cell count with hemolytic anemia can contribute to a client's risk for infection, but this client is more at risk for low oxygen levels and ensuing fatigue. The liver plays a role in blood coagulation, so this client is more at risk for coagulation problems than for infection.

The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective? A. "I can't drink caffeine 24 to 48 hours before the test." B. "I should drink more fluids 4 hours before the test." C. "I'll be placed in a soundproof booth for the test." D. "I'll be sedated for the test."

A. The client must fast for several hours before electronystagmography and avoid caffeine-containing beverages for 24 to 48 hours before the test. Fluids are carefully introduced after the test is completed to prevent nausea and vomiting. The client is placed in a soundproof booth for an audiometry test. The examiners will ask the client to name names or do simple math problems during the test to ensure that he or she stays alert.

A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure? A. Applying pressure to the biopsy site B. Inspecting the site for ecchymoses C. Sending the biopsy specimens to the laboratory D. Teaching the client about avoiding vigorous activity

A. The initial action should be to stop bleeding by applying pressure to the site. Inspecting for ecchymoses, sending specimens to the laboratory, and teaching the client about activity levels will be done after hemostasis has been achieved.

An older adult client comes in for a routine visit. During the assessment, he irritably exclaims, "Speak up and quit mumbling!" How does the nurse respond? A. Apologizes and speaks louder and clearer B. Asks whether the client has a hearing loss C. Offers the client a stethoscope to use D. Suggests that the client move to a soundproof examination room to improve his hearing

A. The nurse should speak more clearly first, and then determine whether further assessment is needed. It should not be assumed that the client has a hearing loss; this suggestion may make the client more irritable, especially if the client is in denial. Using a stethoscope will be effective only once a hearing loss diagnosis has been established. Soundproof rooms are used for hearing tests, not to improve hearing.

A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client? A. Building on the remaining vision B. Keeping the floor free of clutter C. Suggesting a seeing-eye animal companion D. Teaching Braille

A. Using large-print books, talking clocks, and telephones with large, raised block numbers are examples of building on the client's remaining vision, which best facilitates the client's independent self-care. Keeping the floor free of clutter is important but is too specific. A seeing-eye animal companion may be assigned to those who are legally blind, not to those with diminished vision. Braille is used by clients who are legally blind; this client will still be able to read using a magnification device such as a visualizer.

The nurse is teaching a client about visual changes that occur with age. Which statement does the nurse include? A. "It may take your eyes longer to adjust in a darkened room." B. "Most visual changes occur before age 40." C. "When the sclera starts to turn yellow, this means you might have problems with your liver." D. "You probably will have to move reading materials closer to your eyes."

A. With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments. Adults older than 40 years are at increased risk for both glaucoma and cataract formation. Presbyopia also commonly begins in the 40s. The sclera appears yellow or blue as a process of aging, and this condition should not be used to assess for jaundice in the older adult. The near-point of vision (the closest distance at which the eye can see an object clearly) increases with aging. Near objects (especially reading material) must be placed farther from the eye to be seen clearly.

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction? A. "My child should look down at the floor during instillation." B. "I will place the ointment in the lower lid." C. "My child should rub the eye gently after instillation to increase absorption." D. "I will press gently on the inner canthus for 1 minute."

B. After the lower lid is gently pulled down to form a small pocket, eye ointment should be placed in the lower lid. For instillation of eye ointment, the client should tilt the head backward and look up at the ceiling. After closing the eye, the client may gently wipe away any excess ointment with a tissue, but the eye should never be rubbed. Pressing on the inner canthus is a technique reserved for the instillation of glaucoma drops.

A client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? A. Allowing the client's seeing-eye dog in the unit B. Making all health care team members aware of the client's visual limitations C. Keeping the client bedridden for safety D. Addressing the client in a loud, clear voice

B. All health care team members must be made aware of the client's visual limitations and need for assistance. Seeing-eye dogs are not usually allowed in the ICU. It is not necessary to keep the client bedridden. The client should be addressed in a normal tone of voice; the client's hearing is not affected.

The nurse is assessing a client for hematologic function risks and seeks to determine whether there is a risk that cannot be reduced or eliminated. Which clinical health history question does the nurse ask to obtain this information? A. "Do you seem to have excessive bleeding or bruising?" B. "Does anyone in your family bleed a lot?" C. "Tell me what you eat in a day." D. "Where do you work?"

B. An accurate family history is important because many disorders that affect blood and blood clotting are inherited; genetics cannot be changed. Excessive bleeding or bruising is a symptom, not a risk. Diet can affect risk, but it is a health behavior that can be changed. Work habits can be a risk, such as working near radiation, but these are behaviors that can be changed.

A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? A. Aplastic anemia B. Hemolytic anemia C. Infectious process D. Leukemia

B. An elevated reticulocyte count in an anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying RBCs. Therefore, more immature RBCs are in circulation. Aplastic anemia is associated with a low reticulocyte count. A high white blood cell count is expected in clients with infection. A low white blood cell count is expected in clients with leukemia.

A client has recently been diagnosed with 20/200 vision bilaterally. How does the nurse best offer increased support? A. Provides instructions in a loud, clear voice B. Refers the family to local services for the blind C. Tells the client to find a support group D. Writes instructions down in very large print

B. Because the client is considered legally blind, referring the family to local services for the blind is the best way for the nurse to offer increased support. Talking in a loud, clear voice demonstrates insensitivity on the part of the nurse because speaking louder does not have any impact on vision. The client needs more specific assistance than just being told to find a support group. The client with 20/200 vision will not be able to distinguish large print.

The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A. "The doctor will place a small needle in your back and will withdraw some fluid." B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." C. "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area." D. "You will be sedated, so you will not be aware of anything."

B. It is accurate to describe a crunching sound or scraping sensation. Proper expectations minimize the client's fear during the procedure. A very large-bore needle is used for a bone marrow biopsy, not a small needle; the puncture is made in the hip or in the sternum, not the back. The nurse, or sometimes a family member, is available to the client for support during a bone marrow biopsy. The procedure is sterile at the site of the biopsy, but others can be present without contamination at the site. A local anesthetic agent is injected into the skin around the site. The client may also receive a mild tranquilizer or a rapid-acting sedative (such as lorazepam [Ativan]) but will not be completely sedated.

What is the action of miotics in the client with glaucoma? A. Decrease the inflammatory process B. Enhance aqueous outflow C. Increase the production of vitreous humor D. Vasoconstrict the blood vessels in the eye

B. Miotics are used to improve the flow of fluid (aqueous humor) and decrease intraocular pressure in clients with glaucoma. Steroid drops, not miotics, decrease the inflammatory process. Vitreous humor fills the space between the lens and the retina, is stagnant, and is not replenished as the aqueous humor is. Miotics make the pupil smaller, which creates more room between the iris and the lens.

The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased value causes concern because it is not age-related? A. Hemoglobin level B. Platelet (thrombocyte) count C. Red blood cell (RBC) count D. White blood cell (WBC) response

B. Platelet counts do not generally change with age. Hemoglobin levels in men and women fall after middle age; iron-deficient diets may play a role in this reduction. Total RBC and WBC counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people.

The nurse is teaching a client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? A. "I must wait 10 to 15 minutes between different eyedrop medications." B. "I must press on the inside of my eye to prevent washout." C. "It is important to not skip a dose." D. "These eyedrops will not cure my glaucoma."

B. Pressing on the inside of the eye after instillation of eye medication prevents systemic absorption of the drug. To avoid washout, the client should wait 10 to 15 minutes between eyedrop medications. Skipping a dose will not exacerbate the client's glaucoma. Medication will not cure glaucoma, but it will control its progression.

A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" How does the nurse respond? A. "No, they don't." B. "The number varies with gender, age, and general health." C. "Yes, they do." D. "You have fewer red blood cells because you have anemia."

B. Telling the client that the number of red blood cells (RBCs) varies with gender, age, and general health is the most educational and reasonable response to the client's question. Although telling the client that people do not have the same number of RBCs is true, it is not informative, and there is a better answer. While it may be true that the client has fewer red blood cells because of anemia, it does not answer the client's general question.

Which client is most in need of immediate examination by an ophthalmologist? A. A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged B. A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights Correct C. A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes D. A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes

B. The 40-year-old client with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights is exhibiting signs and symptoms of increased intraocular pressure (IOP). This is a priority because the optic nerve can be damaged, which can cause possible blindness. Acute angle-closure glaucoma can occur in those 40 years of age and older. The 58-year-old client reporting an inability to see colors well is exhibiting early signs of cataracts and will need to be seen, but this is not the priority. The 76-year-old with seborrhea of the eyebrows and eyelids is exhibiting signs and symptoms of blepharitis and will need to be seen, but this is also not the priority. The 39-year-old with contacts is exhibiting signs and symptoms of corneal abrasion, possibly from cataracts, and will need to be seen soon, but the client exhibiting increased IOP is still the priority.

After reviewing the laboratory test results, the nurse calls the health care provider about which client? A. A 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 B. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 C. A 49-year-old with hemophilia and a platelet count of 150,000/mm3 D. A 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%

B. The client with a fever is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level. A platelet count of 150,000/mm3 in the 49-year-old is normal. An elevated reticulocyte count in the 52-year-old is expected after hemorrhage.

A client has sustained damage to cranial nerve II after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? A. Artificial tears B. Identifying food on the client's plate using the clock method C. Daily eye assessment using the six cardinal positions of gaze D. Ensuring that the client wears sunglasses when the curtains are open or when the room light is on

B. The optic nerve (cranial nerve [CN] II) controls sight. Using the clock method helps the client with impaired vision or loss of vision locate food on his or her plate. Artificial tears are used when tear production is decreased due to the aging process. The six cardinal positions of gaze assess CN III, IV, and VI. Sunglasses are used when the pupils are artificially dilated for assessment purposes, or when medications are used that cause dilation of the pupil.

Which technique is the correct way to instill eardrops? A. Maintain the head in the same position for 2 minutes after instillation. B. Place the medication bottle in a bowl of warm water before instillation. C. Rinse the ear canal with hydrogen peroxide before instillation. D. Check to see whether the eardrum is intact before instillation.

B. To instill eardrops, place the bottle (with the top on tightly) in a bowl of warm water for 5 minutes. This warms the medication and makes instillation more comfortable for the client. The head should be gently moved back and forth five times after instillation to ensure proper distribution. It is not necessary to rinse the ear canal with hydrogen peroxide or check to see whether the eardrum is intact before instillation.

The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action? A. The eardrum is red, thick-appearing, and immobile. B. The lymph nodes are swollen and painful to touch. C. The client reports a headache and a stiff neck. D. The client's oral temperature is 100.1° F (37.8° C).

C. A headache and a stiff neck may indicate meningitis, which is a serious illness requiring further assessment and immediate intervention. The eardrum being red, thick-appearing, and immobile is an expected finding for a client with an ear infection. Lymph nodes that are swollen and painful to touch are an expected finding for a client with an active infection of the mastoid area. An oral temperature of 100.1° F (37.8° C) is also an expected finding for a client with an active infection.

A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? A. Increased tearing B. Itching of the eye C. Reduction in vision D. Swollen eyelid

C. A reduction in vision after cataract surgery indicates a problem, and the client should notify the provider immediately. Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? A. Administer a Snellen test. B. Obtain an informed consent. C. Wash the hands. D. Put on sterile gloves.

C. Always wash hands before touching the external eye structures to prevent infection. A Snellen test may be done, but is not the first thing that should be done by the nurse. An informed consent or sterile gloves are not needed for the nurse to examine the client's eye.

The nurse is providing postmortem care to a client who has donated a cornea. Which action is appropriate for the nurse to implement? A. Apply a warm pack to the eyes. B. Elevate the lower extremities. C. Instill antibiotic drops into the eyes. D. Contact the recipient family.

C. Antibiotic eyedrops, such as Neosporin (polymyxin B, neomycin, bacitracin) or tobramycin, should be instilled into the corneal donor's eyes to prevent infection. Small cold packs should be applied to the donor's closed eyes. Raising the head of the bed 30 degrees prevents blood from pooling in the eye region of the deceased client. The nurse is not the person to contact the recipient family; the donor organization will complete all the communication to the parties involved.

A client on anticoagulant therapy is being discharged. Which statement indicates that the client has a correct understanding of this therapy's purpose or action? A. "It is to dissolve blood clots." B. "It might cause me to get injured more often." C. "It should prevent my blood from clotting." D. "It will thin my blood."

C. Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots. Anticoagulants do not dissolve clots, fibrinolytics do. Anticoagulants do not cause more injuries, but may cause more bleeding and bruising when the client is injured. Anticoagulants do not cause any change in the thickness or viscosity of the blood.

The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question does the nurse ask the client? A. "Can you prepare your own meals?" B. "Has your weight changed by 5 pounds or more this year?" C. "How is your energy level compared with last year?" D. "What medications do you take daily, weekly, and monthly?"

C. Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance for ADLs. The client may never have been able to prepare his or her own meals, and the ability to prepare meals does not really address endurance. The question about weight change addresses nutrition and metabolic needs, rather than ADL performance. The question about how often the client takes medication addresses nutrition and metabolic needs and focuses on health maintenance through the use of drugs, not on the client's ability to perform ADLs.

Which action does the nurse delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a female client with anemia? A. Asking the client about the amount of blood loss with each menstrual period B. Checking for sternal tenderness while applying fingertip pressure C. Determining the respiratory rate before and after the client walks 20 feet D. Monitoring her oral mucosa for pallor, bleeding, or ulceration

C. Assessment of the respiratory rate before and after ambulation is within the scope of practice for UAP; UAP will report this information to the RN. Asking the client about the amount of blood loss with each menstrual period, checking for sternal tenderness, and monitoring oral mucosa require skilled assessment techniques and knowledge of normal parameters and should be done by the RN.

A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? A. "I will get some books on tape for entertainment." B. "I will be sure to pick up all clutter and loose carpets from the floor." C. "I will rearrange the furniture for better flow before my spouse gets home." D. "I will place a nonslip mat in the bathtub."

C. Changes in item location should not be made without input from the client with reduced vision. Books on tape are a good diversion for recuperating clients with reduced vision. Any objects that may present a tripping hazard should be removed at once. A nonslip mat may be used to prevent falls in the bathtub.

Which client does the medical unit charge nurse assign to an LPN/LVN? A. A 23-year-old scheduled for a bone marrow biopsy with conscious sedation B. A 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) C. A 48-year-old with chronic microcytic anemia associated with alcohol use D. A 62-year-old with atrial fibrillation and an international normalized ratio of 6.6

C. Chronic microcytic anemia is not considered life-threatening and can be assigned to an LPN/LVN. The clients with a bone marrow biopsy with conscious sedation, a history of splenectomy and a temperature, and atrial fibrillation require more complex assessment or nursing care and should be assigned to RN staff members.

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? (Select all that apply.) A. Acetaminophen (Tylenol) B. Beta blockers C. Erythromycin D. Ibuprofen (Advil) E. Insulin F. Furosemide (Lasix)

C. D. F. Erythromycin, ibuprofen, and furosemide (Lasix) are medications known to increase the risk for ototoxicity and hearing problems. Acetaminophen, beta blockers, and insulin are not known ototoxic drugs.

The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? (Select all that apply.) A. Cab driver B. College student C. Lifeguard D. Racquetball player E. Registered nurse

C. D. Lifeguards are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play racquetball need to wear protective eyewear to prevent possible eye injury. Cab drivers may require eyewear for corrective purposes, but are not at high risk and in need of protective eyewear. College students are generally not at high risk. Although an RN would need eye protection at times, RNs do not routinely require protective eyewear for general work.

The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first? A. Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic B. Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side C. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache D. Client who has acute otitis media and is reporting drainage from the affected ear

C. Elevated temperature and headache with labyrinthitis may indicate that the client has developed meningitis and requires further immediate assessment and intervention. Severe nausea is an expected finding with Ménière's disease. Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma. Drainage from the affected ear can be an expected finding with otitis media.

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? A. Bilateral eye patches B. Contact lenses C. Nothing; this is normal D. Reading glasses

C. Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment. Bilateral eye patches inhibit the client's vision. Contact lenses are used to correct underrefraction of the eye. Reading glasses are used to correct overrefraction of the eye.

The clinic nurse is discharging a 20-year-old client who had a bone marrow aspiration performed. What does the nurse advise the client to do? A. "Avoid contact sports or activity that may traumatize the site for 24 hours." B. "Inspect the site for bleeding every 4 to 6 hours." C. "Place an ice pack over the site to reduce the bruising." D. "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."

C. Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. The client should carefully monitor the site every 2 hours for the first 24 hours after the procedure. A mild analgesic is appropriate, but it should be aspirin-free; acetaminophen (Tylenol) would be a good choice.

Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? A. Antihistamines B. Antipyretics C. Diuretics D. Nicotinic acid

C. Mild diuretics are prescribed to decrease endolymph volume. Antihistamines help reduce the severity of or stop an acute attack, and antipyretics control fever and pain, but they do not decrease endolymph volume. Nicotinic acid has been found to be useful because of its vasodilatory effect, but it does not decrease endolymph volume.

A client with a low platelet count asks why platelets are important. How does the nurse answer? A. "Platelets make your blood clot." B. "Blood clotting is prevented by your platelets." C. "The clotting process begins with your platelets." D. "Your platelets finish the clotting process."

C. Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis. Platelets do not clot blood; they are a part of the clotting process or cascade of coagulation. Platelets do not prevent the blood from clotting; rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it.

The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? A. "Here is a picture of how the test is done. See how your bad ear will be tested first? You will be alone in the soundproof booth, so you will need to watch for lights flashing on and off as your cues." B. "Here is a video of the procedure. Please watch and feel free to ask me any questions." C. "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." D. "You will be in a soundproof booth and the sounds will be piped in. When you first hear the loudest sound, put your hand down. When you stop hearing the sound, put your hand up to stop."

C. Sitting in front of the hearing-impaired client while providing instructions allows the client to read lips. Pictures help the client with impaired hearing, but the good ear is tested first. The client wears earphones and listens for sounds, not flashing lights. Showing a hearing-impaired client a video is ineffective because of tone and frequency differences in the video, which make it difficult to read lips and understand the instructions. During the test, earphones are placed on the client. The client will raise her or his hand up when hearing the first sound and will lower the hand when the sound first disappears.

Which proper technique does the nurse use for eyedrop instillation? A.Instilling the drops into the inner canthus B. Opening the eye by raising the upper eyelid C. Placing the eyedrop in the lower lid pocket D. Touching the bottle tip to the eyeball

C. To instill eyedrops, the lower eyelid is gently pulled down against the cheek to form a pocket, and the medication is instilled. Instilling drops into the inner canthus causes the medication to enter the punctum and be absorbed systemically. The upper eyelid is larger than the lower eyelid and is used to protect the eye and keep the cornea moist; it should not be used to create a pocket to instill medication. Touching the bottle tip to any part of the eye could potentially contaminate the eye.

Sickle cell disease (SCD): genetic disorder that results in chronic anemia, pain, disability, organ damage, increased risk of infections, and early death

Conditions that cause sickling: hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol consumption, high altitudes, low or high environmental or body temp, acidosis, strenuous exercise, emotional stress, and anesthesia.

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? "I may have problems with vertigo after the surgery." "I should not drink from a straw for several weeks." "I will have to take antibiotics after the surgery." "I will be able to hear as soon as my dressing is removed."

D.

An older adult client expresses concern about the ability to instill over-the-counter eyedrops, saying, "My vision is getting so bad, I can't even see my own eyes." What is the nurse's best response? A. "Don't worry about the eyedrops." B. "Getting old isn't fun, is it?" C. "Can your daughter help you do it?" D. "Let's find a way that will work for you."

D. Assessing the client's ability to self-perform and adjusting the steps of eyedrop instillation to accommodate the client's change in vision promote independence. Telling the client not to worry about the eyedrops falsely reassures the client and blocks communication. Diverting the client's concern over the inability to instill eyedrops with a comment about getting old blocks communication. Suggesting that the client's daughter help does not promote client independence.

Which assessment finding warrants further investigation by the nurse in the ophthalmology clinic? A. Snellen eye examination result is 20/50 for a client who normally wears corrective lenses, but does not have them at the time of the examination. B. When six cardinal positions of gaze of the left eye are assessed, the client exhibits nystagmus when looking to the left lower and upper fields. C. The pupil exhibits miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil. D. When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.

D. Cloudiness in the cornea and pain from a light shined into the pupil is an abnormal finding that requires further assessment and possible intervention/referral. A Snellen eye examination result of 20/50 for the client who normally wears corrective lenses but does not have them at the time of the examination is normal given the client's baseline and considering that he or she wears corrective lenses. It can be a normal finding for the client to exhibit nystagmus when looking to the left lower and upper fields during assessment of the six cardinal positions of gaze of the left eye. It is normal for the pupil to exhibit miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil.

Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? A. Anisocoria B. Presbyopia C. Diabetic retinopathy D. Glaucoma

D. Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year. Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population; this condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near objects; increased IOP is not a factor. Diabetic retinopathy is microvascular damage caused by uncontrolled diabetes, not by increased IOP.

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? A. Burning in the eye B. Inability to differentiate colors C. Increased sensitivity to light D. Gradual vision changes

D. Gradual vision changes are an indication of increased intraocular pressure. A burning sensation in the eye usually indicates inflammation and/or infection. An inability to differentiate colors is an early sign of cataracts. An increased sensitivity to light might be a sign of a corneal abrasion.

The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? A. Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) B. Determines who prepares the client's meals and plans an interview with him or her C. From a prepared list, finds out the client's food preferences D. Has the client write down everything he or she has eaten for the past week

D. Having the client provide a list of items eaten in the past week is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as protein, vitamin, and mineral intake. Rating scales are good for subjective data collection about some conditions such as pain, but the subjectivity of a response such as this does not provide the nurse with specific data needed to assess a diet. Interviewing the food preparer is time-consuming and poses several problems, such as whether a number of people are preparing meals, or if the client goes "out" for meals. Determining food preferences from a prepared list provides information about what the client enjoys eating, not necessarily what the client has been eating; for instance, the client may like steak but may be unable to afford it.

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? A. "I may have problems with vertigo after the surgery." B. "I should not drink from a straw for several weeks." C. "I will have to take antibiotics after the surgery." D. "I will be able to hear as soon as my dressing is removed."

D. Hearing is initially worse after a stapedectomy. The client should be informed that improvement in hearing may not occur until 6 weeks after surgery. At first, the ear packing interferes with hearing. Swelling in the ear after surgery reduces hearing, but this condition is temporary. Vertigo, nausea, and vomiting are common after surgery because of the nearness of the surgical site to inner ear structures. Clients should not drink through a straw for 2 to 3 weeks after surgery. Antibiotics are used to reduce the risk for infection.

What is the proper technique for assessing an adult client's ear with an otoscope? A. Hold the otoscope right side up when inserting it into the ear canal. B. Maintain distance between the otoscope and the client's head. C. Place the otoscope in the nondominant hand. D. Pull the pinna up and back with the nondominant hand.

D. In the adult, pulling the pinna up and back allows the ear canal to straighten. The otoscope should be held upside down, like a large pen. The distance between the otoscope and the client's head is very short. The otoscope should be held in the dominant hand.

A client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client? A. On the affected side B. Supine, with eyes toward the ceiling C. With the head elevated 60 degrees D. With the affected ear facing up

D. Keep the client flat, with the head turned to the side and the operative ear facing up, for at least 12 hours after surgery. Raising the head places undue pressure on the surgical site.

The nurse is teaching a client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? A. "Background noises will be difficult for me to hear." B. "I should wear my hearing aid only to work at first." C. "I should just get a smaller hearing aid because I don't have much money." D. "Listening to the radio and television will help me get used to new sounds."

D. Listening to television and the radio and reading aloud can help the client get used to new sounds. With hearing aids, background noises are amplified so the client must learn to concentrate and filter out background noises. The client should start using the hearing aid slowly, at first wearing it only at home and only during part of the day. The cost of smaller hearing aids is actually greater than for larger ones.

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? A. "I may need to use a cane." B. "I should keep my grandkids' toys out of the hallway." C. "Moving more slowly may help the vertigo subside." D. "Taking my medication will allow me to drive my car again."

D. Medications for vertigo may cause drowsiness, so the client should not drive or operate machinery while taking these drugs. The client with vertigo may need to use a cane for balance. Clients should maintain a safe, uncluttered environment to prevent accidents during periods of vertigo. Restricting head motion and moving more slowly may help clients reduce occurrences of vertigo.

The nurse is talking to a client about ear hygiene safety. Which statement by the client indicates a need for further teaching? A. "After I shower, I dry my ears using my fingertip and a towel." B. "I irrigate my ears with tap water." C. "I never clean my ears with a cotton swab." D. "I use a bobby pin to remove earwax."

D. Nothing smaller than the client's own fingertip should be inserted into the ear canal. Use of a bobby pin or cotton swab can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum. Using the fingertip and a towel and irrigating the ear canal with tap water are acceptable.

Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Drawing a partial thromboplastin time from a saline lock on a client with a pulmonary embolism B. Performing a capillary fragility test to check vascular hemostatic function on a client with liver failure C. Referring a client with a daily alcohol consumption of 12 beers for counseling D. Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia

D. Reporting findings during routine care is expected and required of unlicensed staff members. Drawing a partial thromboplastin time, performing a capillary fragility test, and referring a client for alcohol counseling are more complex and should be done by licensed nursing staff.

A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? A. Provide further assessment. B. Suggest a quiet environment. C. Suggest temporary removal of a hearing aid. D. Refer the client to the American Tinnitus Association.

D. The American Tinnitus Association assists clients in coping with tinnitus when other therapy is unsuccessful. Reassessment of the client's diagnosis is not needed; this will only waste the client's and the nurse's time. Background noise masks the tinnitus while quiet conditions exacerbate it; ear-mold hearing aids can amplify sounds to drown out tinnitus during the day.

An older adult client with a new diagnosis of hearing loss is deeply concerned about not being able to hear at the neighborhood council meetings. Which nursing intervention best addresses the client's concern? A. Suggest that the client discuss with the chairperson about asking everyone speaking at the meeting to speak louder. B. Refer the client to the Center for the Visually Impaired for support. C. Arrange for a sign language specialist to attend the meetings to teach everyone how to communicate with the hearing-impaired member. D. Refer the client to the Hearing Loss Association of America.

D. The Hearing Loss Association of America can inform the client about support groups in the area, along with interventions to help improve hearing. Speaking louder raises the frequency of the sound, making it more difficult to hear. The Center for the Visually Impaired is useful for people with vision problems, not hearing problems. The client and members of the neighborhood council must first express an interest in learning sign language before arrangements are made with a sign language specialist.

A client says, "I have problems reading the signs when I am driving." Which test does the nurse use to assess this client's problem? A. Confrontation test B. Ishihara chart C. Rosenbaum Pocket Vision Screener or a Jaeger card D. Snellen chart

D. The Snellen chart assesses the client's distance vision, which is the type of vision used while driving. The confrontation test assesses the client's visual field. The Ishihara chart assesses the client's color vision. The Rosenbaum Pocket Vision Screener or Jaeger card assess the client's near vision.

When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? A. "One eye is green and the other eye is blue." B. "My eyes are red and itchy." C. "My vision has been getting worse gradually." D. "Something hit my eye while I was cutting grass."

D. The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist. Heterochromia is an ocular condition, usually genetically inherited, that causes the iris to vary in color; this is not an emergency. Itching and redness can be caused by allergies, irritation, or ocular drug effects, but do not require immediate attention. Gradual vision loss could be caused by uncontrolled hypertension and diabetes, but does not require immediate care by an ophthalmologist.

The nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? A. A 42-year-old with anemia who is reporting shortness of breath when ambulating down the hallway B. A 47-year-old who recently had a Rumpel-Leede test and is requesting a nurse to "look at the bruises on my arm" C. A 52-year-old who has just had a bone marrow aspiration and is requesting pain medication D. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism

D. The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for the severity of the situation first. The client with anemia and the client who had a Rumpel-Leede test are more stable, and can be assessed later. Making clients wait for pain medication is not desirable, but in this scenario, the client who is bleeding is the higher priority. The client waiting for pain medication should be next on the nurse's "to do" list.

When preparing to examine an ear with drainage, what does the nurse do first? A. Begins testing at 1000 Hz B. Reassures the client that the ear drainage is normal C. Tilts the client's head away slightly D. Dons clean gloves

D. The nurse should always use Contact Precautions, which include wearing clean gloves, with any client who has drainage from the ear canal to prevent infection. Testing for hearing loss (1000 Hz) is not used when examining an ear for drainage. Ear drainage is not normal and must be investigated. Tilting the client's head is not the first action among the options given that the nurse should do.

A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? A. "How many hours are you sleeping at night?" B. "You are not getting enough iron." C. "You need to rest more when you are sick." D. "Your cells are delivering less oxygen than you need."

D. The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs. Although assessment of sleep and rest is good, it does not address the cause related to the diagnosis. While it may be true that the client isn't getting enough iron, it does not relate to the client's fatigue. The statement about the client needing rest because of being sick is simply not true.

A client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? A. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine). B. Hold the client's hand and ask about concerns. C. Review the client's platelet (thrombocyte) count. D. Verify that the client has given informed consent.

D. Verifying informed consent must be done before the procedure can be performed. A signed permit must be on the client's chart. Cleaning the biopsy site is done before the procedure, but this is not done until consent is verified; it will be done just before the procedure is performed. Holding the client's hand and offering verbal support may be done during the procedure, but the procedure cannot be completed until the consent is signed. Reviewing the client's platelet count is not imperative.

An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? A. Dry, flaky cerumen B. Pain on movement of the tragus C. Ringing in the ears D. Vertigo

D. With otitis media, as pressure on the middle ear pushes against the inner ear, the client may develop dizziness or vertigo. Dry, flaky cerumen is normal with aging. Pain on movement of the tragus is indicative of external otitis. Ringing in the ears is more likely with Ménière's disease.

Skin color: skin color changes, especially pallor or jaundice, are associated with some hematologic disorders.

Normal changes in aging adult: pigment loss and skin yellowing are common changes associated with aging; pallor in an older adult may not be reliable, lab testing is required. Yellow-tinged skin in an older adult is also unreliable. Labs are needed.

Hair distribution: thin or absent hair on the trunk or extremities may indicate poor circulation to a particular area

Normal changes in aging adult: progressive hair loss is a normal part of aging; a relatively even pattern of hair loss that has occurred over an extended period of time is not significant

Nail beds (for capillary refill): pallor or cyanosis may indicate a hematologic disorder

Normal changes in aging adult: thickened or discolored nails make viewing color of the nail beds impossible; use another area such as the lip to assess central capillary refill

Hyperopia (farsightedness): distant vision is normal; but near vision is poor

Occurs when the eye does not refract light enough. As a result, images converge behind the retina

Myopia (nearsightedness): near visions is normal; but distant vision is poor

Occurs when the eye overbends the light and images converge in front of the retina