Med Surg II Exam 1, review part 2
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? 1. oral analgesics such as ibuprofen or acetaminophen 2. intravenous opioids 3. intramuscular opioids 4. oral antianxiety agents such as lorazepam
2. intravenous opioids
The nurse is discharging a client who just had cataract removal and intraocular lens implantation. The nurse is confident the client understands discharge instructions when the client states (select all that apply): 1. "I understand the schedule for my eyedrops and will use the medications." 2. "I feel good and am ready to drive home now." 3. "I will call in the morning if I cannot see clearly." 4. "I will wear the eye shield at night to protect my eye." 5. "I will avoid lifting or pulling anything over 15 lb (6.8 kg)." 6. "I will call if I still have eye pain after taking acetaminophen."
1. I understand the schedule for my eye-drops and will use the medications. 4. I will wear the eye shield at night to protect my eye. 5. I will avoid lifting or pulling anything over 15lb (6.8kg). 6. I will call if I still have eye pain after taking acetaminophen.
The rate at which IV fluids are infused is based on the burn client's: 1. lean muscle mass and body surface area (BSA) burned. 2. total body weight and BSA burned. 3. total BSA and BSA burned. 4. height and weight and BSA burned.
2. total body weight and BSA burned
The nurse is observing a spouse administer eyedrops. What should the nurse instruct the spouse to do? 1. Move the dropper to the inner canthus. 2. Have the client raise the eyebrows. 3. Administer the drops in the center of the lower lid. 4. Have the client squeeze both eyes after administering the drops.
3. Administer the drops in the center of the lower lid
After the initial phase of the burn injury, the client's plan of care will focus primarily on: 1. helping the client maintain a positive self-concept. 2. promoting hygiene. 3. preventing infection. 4. educating the client regarding care of the skin grafts.
3. preventing infection
The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? 1. Clean the wounds with warm water. 2. Apply antibiotic cream. 3. Refer the client to a burn center. 4. Cover the burns with a sterile dressing.
3. refer the client to a burn center
68. When educating a female client with gonorrhea, the nurse should emphasize that for women, gonorrhea: a. is often marked by symptoms of dysuria or vaginal bleeding b. does not lead to serious complications c. can be treated but not cured d. may not cause symptoms until serious complications
d. may not cause symptoms until serious complications
74. The nurse is administering didanosine to a client with HIV. Before administering this medication, the nurse should check which lab test results? Select all that apply. a. elevated serum creatinine b. elevated blood urea nitrogen (BUN) c. elevated aspartate aminotransferase (AST) d. elevated alanine aminotransferase (ALT) e. elated serum amylase
c. elevated aspartate aminotransferase (AST) d. elevated alanine aminotransferase (ALT) e. elated serum amylase
A nurse is caring for an older adult with shingles. The client is experiencing considerable pain related to open blisters on the client's abdomen and back. The client is taking acyclovir and low-dose prednisone. The nurse has several prescriptions available. What additional medications or nursing care strategies to promote comfort may be helpful? Select all that apply. 1. diphenhydramine 25 mg by mouth every 6 hours prn 2. calamine lotion applied to the affected areas 3. cool, wet compresses to the affected areas 4. acetaminophen 325 mg by mouth every 6 hours prn 5. ondansetron 4 mg by mouth every 4 hours prn 6. diversionary activities to prevent client scratching
1. diphenhydramine 25 mg by mouth every 6 hours pro 2. calamine lotion applied to the affected areas 3. cool, wet compresses to the affected areas 4. acetaminophen 325 mg by mouth every 6 hours pro 6. diversionary activities to prevent client from scratching
70. A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What documentation should be included on the client's medical record? Select all that apply. 1. history of unprotected sex (sex without a condom) 2. length of time since symptoms presented 3. history of fever or chills 4. presence of any enlarged lymph nodes on examination 5. names and phone numbers of all sexual contacts 6. allergies to any medications
1. history of unprotected sex (sex without a condom) 2. length of time since symptoms presented 3. history of fever or chills 4. presence of any enlarged lymph nodes on examination 6. allergies to any medications
Which interventions would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate? 1. Ensure parental support during the dressing changes. 2. Allow the child to assist in removing the dressings and applying the cream. 3. Give the child permission to cry during the procedure. 4. Allow the child to schedule the time for dressing changes.
2. Allow the child to assist in removing the dressings and applying the cream
An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? 1. Keep all the lights on in the room at all times. 2. Use a night-light in the bathroom. 3. Keep all four side rails up at all times. 4. Place the client in a room with a camera monitor.
2. Use a night-light in the bathroom
The nurse is to administer an antibiotic to a client with burns, but there is no medication in the client's medication box. What should the nurse do first? 1. Inform the unit's shift coordinator. 2. Contact the client's healthcare provider (HCP). 3. Call the pharmacy department. 4. Borrow the medication from another client. 3. By contacting the pharmacy to report the absence of the medication, the pharmacy can bring the medication to the client's medication box. From there on, the pharmacy can make sure the correct medications are present. Contacting the shift coordinator or the client's HCP A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? Select all that apply. 1. atrial fibrillation 2. advancing age 3. type 2 diabetes mellitus 4. hypertension 5. smoking
2. advancing age 3. type 2 diabetes mellitus 5. smoking
The nurse should plan to begin rehabilitation efforts for the burn client: 1. immediately after the burn has occurred. 2. after the client's circulatory status has been stabilized. 3. after grafting of the burn wounds has occurred. 4. after the client's pain has been eliminated.
2. after the client's circulatory status has been stabilized
The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot. The client originally scraped the foot on a rock while walking barefoot outside; the scrape became infected and eventually required hospitalization for wound care and several days of IV antibiotics. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse? 1. "I will eat lots of fruit and vegetables and take vitamin C to help this heal." 2. "I will be sure to wear shoes to protect my feet when I go out to get the mail." 3. "I will manage my pain by putting this foot up on a pillow when it hurts." 4. "I will take the antibiotics until the redness goes away and my foot feels better." 4. It is important for the client to understand the need to complete the entire course of oral antibiotics as prescribed in order to prevent recurrence/worsening of cellulitis. Further, if the pain and redness continue despite antibiotics, the client needs to understand the need to follow up with the healthcare provider. Extra vitamin C, protective footwear, and elevating the foot are strategies to promote healing. Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to: 1. altered balance. 2. altered protective pressure sensation. 3. impaired hearing ability. 4. impaired visual acuity
2. altered protective pressure sensation
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: 1. encourage the formation of tough skin. 2. promote the growth of epithelial tissue. 3. provide for permanent wound closure. 4. facilitate the development of subcutaneous tissue.
2. promote the growth of epithelial tissue
A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and the parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching? 1. deciding that she will feed the child herself 2. withholding dessert and treats unless meals are eaten 3. offering the child finger foods that the child likes 4. serving smaller and more frequent meals
2. withholding dessert and treats unless the meals are eaten
When teaching an adolescent with facial acne about skin care, the nurse should instruct the adolescent to: 1. wash the face twice a day with mild soap and water. 2. remove whiteheads and comedones after washing the face with antibacterial soap. 3. apply vitamin E ointment twice daily to the affected skin. 4. apply tretinoin daily in the morning and expose the face to the sun. 1. Washing the face once or twice a day with a mild soap removes fatty acids from the skin. Acne is an inflammation of the sebaceous glands that produce sebum. Washing the face with mild soap and water keeps the sebaceous glands from becoming plugged. Excessive washing or squeezing the eruptions can cause rupture of these glands, spreading the sebum and causing further inflammation. Applying vitamin E to the lesions does not reduce the inflammation and, due to the greasiness of the preparation, may plug the ducts. Isotretinoin should be applied at night. Exposure to the sun can result in sunburn and an increased risk of skin cancer and should be avoided. Sunscreen with a sun protection factor of at least 15 must be applied before the client can be exposed to the sun. After the nurse teaches the mother of a child with atopic dermatitis how to bathe her child, which statement by the mother indicates effective teaching? 1. "I let my child play in the tub for 30 minutes every night." 2. "My child loves the bubble bath I put in the tub." 3. "When my child gets out of the tub I just pat the skin dry." 4. "I make sure my child has a bath every night."
3. "When my child gets out of the tub I just pat the skin dry."
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. 1. 18% 2. 27% 3. 45% 4. 64%
3. 45%
A client has been admitted to the hospital with draining foot lesions. What should the nurse do? Select all that apply. 1. Place the client in a room with negative air pressure. 2. Admit the client to a semiprivate room. 3. Admit the client to a private room. 4. Post a "contact isolation" sign on the door. 5. Wear a protective gown when in the client's room. 6. Wear gloves when providing direct care
3. Admit the client to a private room. 4. Post a "contact isolation" sign on the door. 5. Wear a protective gown when in the client's room 6. Wear gloves when providing direct care
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider (HCP) with a recommendation for: 1. furosemide. 2. fresh frozen plasma. 3. IV rate increase. 4. dextrose 5%.
3. IV rate increase
At about one-half hour before the daily whirlpool bath and dressing change, the nurse should: 1. soak the dressing. 2. remove the dressing. 3. administer an analgesic. 4. slit the dressing with blunt scissors.
3. administer an analgesic
A nurse is caring for an older adult with shingles. The client is experiencing considerable pain related to open blisters on the client's abdomen and back. The client is taking acyclovir and low-dose prednisone. The nurse has several prescriptions available. What additional medications or nursing care strategies to promote comfort may be helpful? Select all that apply. 1. diphenhydramine 25 mg by mouth every 6 hours prn 2. calamine lotion applied to the affected areas 3. cool, wet compresses to the affected areas 4. acetaminophen 325 mg by mouth every 6 hours prn 5. ondansetron 4 mg by mouth every 4 hours prn 6. diversionary activities to prevent client scratching 1,2,3,4,6. Diphenhydramine is an antihistamine that reduces allergic reactions, calamine lotion is a topical antipruritic, and acetaminophen is an analgesic. These medications may help increase client comfort by reducing pain, inflammation, and itching, which, in turn, may reduce client scratching and potentially spreading the virus. Cool wet compresses also relieve itching and pain. Ondansetron is an antiemetic and would not be helpful for this client's discomfort. The nurse is assessing a client with dark skin for the presence of a stage I pressure ulcer. The nurse should: 1. use a fluorescent light source to assess the skin. 2. inspect the skin only when the Braden score is above 12. 3. look for skin color that is darker than the surrounding tissue. 4. avoid touching the skin during inspection.
3. look for skin color that is darker than the surrounding tissue.
The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to: 1. apply a moist to moist dressing, being careful to pack just the wound bed. 2. consult with a wound-ostomy-continence nurse specialist. 3. reposition the client off of the reddened skin and reassess in a few hours. 4. complete and document a Braden skin breakdown risk score for the client.
3. reposition the client off the reddened skin and reassess in a few hours.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1″ × 1″ (3 cm × 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? 1. stage I pressure ulcer 2. stage II pressure ulcer 3. stage III pressure ulcer 4. stage IV pressure ulcer
3. stage III pressure ulcer
The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? 1. pulse rate of 112 bpm 2. blood pressure of 94/64 mm Hg 3. urine output of 30 mL/h 4. serum sodium level of 136 mEq/L (136 mmol/L
3. urine output of 30mL/h
The client has had a cataract removed. The nurse's discharge instructions should include telling the client to: 1. keep the head aligned straight. 2. utilize bright lights in the home. 3. use an eye shield at night. 4. change the eye patch as needed.
3. use an eye shield at night.
One day after cataract surgery, the client is having discomfort from bright light. The nurse should advise the client to: 1. dim lights in the house and stay inside for 1 week. 2. attach sun shields to existing eyeglasses when in direct sunlight. 3. use sunglasses that wrap around the side of the face when in bright light. 4. patch the affected eye when in bright light.
3. use sunglasses that wrap around the side of the face when in bright light
An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? 1. Keep all the lights on in the room at all times. 2. Use a night-light in the bathroom. 3. Keep all four side rails up at all times. 4. Place the client in a room with a camera monitor. 2. Many falls occur when older clients attempt to get to the bathroom at night. The risk is even greater in an unfamiliar environment. Use of a night-light in the bathroom enables the older adult client to see the way to the bathroom. Keeping the lights on in the room at all times may contribute to sensory overload and prevent adequate rest. Raised side rails paradoxically contribute to falls when the older client tries to climb over them to get to the bathroom. The upper side rails may be raised, but it is not recommended that all four side rails be elevated. Camera monitoring can be used but does nothing to prevent a fall. The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot. The client originally scraped the foot on a rock while walking barefoot outside; the scrape became infected and eventually required hospitalization for wound care and several days of IV antibiotics. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse? 1. "I will eat lots of fruit and vegetables and take vitamin C to help this heal." 2. "I will be sure to wear shoes to protect my feet when I go out to get the mail." 3. "I will manage my pain by putting this foot up on a pillow when it hurts." 4. "I will take the antibiotics until the redness goes away and my foot feels better."
4. "I will take the antibiotics until the redness goes away and my foot feels better."
When developing the teaching plan for the mother of a 2-year-old child diagnosed with scabies, what information should the nurse expect to include? 1. The floors of the house should be cleaned with a damp mop. 2. The child should be held frequently. 3. Itching should cease in a few days. 4. The entire family should be treated.
4. The entire family should be treated
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: 1. correct water and electrolyte imbalances. 2. allow the gastrointestinal tract to rest. 3. provide supplemental vitamins and minerals. 4. ensure adequate caloric and protein intake.
4. ensure adequate caloric and protein intake
A short time after cataract surgery, the client has nausea. The nurse should first: 1. instruct the client to take a few deep breaths until the nausea subsides. 2. explain that this is a common feeling that will pass quickly. 3. tell the client to call the nurse promptly if vomiting occurs. 4. medicate the client with an antiemetic, as prescribed.
4. medicate the client with an antiemetic, as prescribed
A client tells the nurse about the vision being blurred and hazy throughout the entire day. The nurse should recommend that the client: 1. purchase a pair of magnifying glasses. 2. wear glasses with tinted lenses. 3. schedule an appointment with an optician. 4. schedule an appointment with an ophthalmologist.
4. schedule an appointment with an ophthalmologist.
Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? 1. absence of infection in the wounds 2. adequate vascularization in the grafted area 3. immobilization of the area being grafted 4. use of analgesics as necessary for pain relief
4. use of analgesics as necessary for pain relief
Using the Parkland formula, calculate the hourly rate of fluid replacement with lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%. Record your answer using a whole number. ________________________________ mL/h
750ml
65. The nurse is interviewing a client with newly diagnosed syphilis. In order to prevent the spread of the disease, the nurse should focus the interview by a. motivating the client to undergo treatment. b. obtaining a list of the client's sexual contacts c. increasing the client's knowledge of the disease d. reassuring the client that medical records are confidential
b. obtaining a list of the client's sexual contacts
73. The nurse assesses the mouth and oral cavity of a client with human immunodeficiency virus (HIV) infection because the most common opportunistic infection initially presents as: a. herpes simplex virus (HSV) lesions on the lips b. oral candidiasis c. cytomegalovirus (CMV) infection d. aphthae on the gingiva
b. oral candidiasis
93. A 28-year-old male is diagnosed with acute epididymitis. The nurse should assess the client for: a. boring and pain on urination b. severe tenderness and swelling in the scrotum c. foul-smelling ejaculate d. foul-smelling urine
b. severe tenderness and swelling in the scrotum
66. Benzathine penicillin G, 2.4 million units IM, is prescribed as treatment for an adult client with primary syphilis. The nurse should administer the injection in the a. deltoid b. upper outer quadrant of the buttock c. quadriceps laterals of the thigh d. mid lateral aspect of the thigh
b. upper outer quadrant of the buttock
2. A nurse is teaching a client how to prevent a vaginal infection. Which activity puts the client at risk for altering the normal pH of her vagina? a. consuming over four cups of coffee per day b. having sexual intercourse during the menstrual cycle c. douching unless instructed to do so by the healthcare provider (HCP) d. using tampons during the menstrual cycle
c. douching unless instructed to do so by the healthcare provider (HCP)`
47. The nurse is reviewing the medication history of a client with benign prostatic hypertrophy (BPH). Which medication will likely aggravate BPH? a. metformin b. buspirone c. inhaled ipratropium d. ophthalmic timolol
c. inhaled ipratropium
63. A male client with human immunodeficiency virus (HIV) infection becomes depressed and tells the nurse: "I have nothing worth living for now." Which statement would be the best response by the nurse? a. "You are a young person and have a great deal to live for." b. "You should not be too depressed; we are close to finding a cure for AIDS." c. You are right; it is very depressing to have HIV." d. "Tell me more about how you are feeling about being HIV positive."
d. "Tell me more about how you are feeling about being HIV positive."
72. A female client with gonorrhea informs the nurse that she has had sexual intercourse with her boyfriend and asks the nurse, "Would he have any symptoms?" The nurse responds that in men, the symptoms of gonorrhea include: a. impotence b. scrotal swelling c. urine retention d. dysuria
d. dysuria
62. When teaching a client about human immunodeficiency virus (HIV), the nurse should take into account the fact that the most effective method known to control the spread of HIV infection is a. premarital serologic screening b. prophylactic treatment of exposed people c. laboratory screening of pregnant women d. ongoing sex education about preventive behaviors
d. ongoing sex education about preventive behaviors
Which clinical manifestation should the nurse assess when a client has acute angle-closure glaucoma? 1. gradual loss of central vision 2. acute light sensitivity 3. loss of color vision 4. sudden eye pain
4. sudden eye pain
A client is admitted with pneumonia and shingles with draining lesions over the right anterior and posterior chest wall. Of the nurses scheduled for the shift, which nurses may be assigned to care for this client? Select all that apply. 1. 43-year-old female who had a preexposure varicella vaccination 2. 48-year-old male who had shingles 1 year prior 3. 32-year-old female who is in the first trimester of pregnancy 4. 24-year-old female who has never had the pneumococcal vaccine 5. 36-year-old male taking steroids for an autoimmune disease
1. 43-year-old female who had a preexposure varicella vaccination 2. 48-year-old male who had shingles 1 year prior 4. 24-year-old female who has never had the pneumococcal vaccine
The client with retinal detachment in the right eye is extremely apprehensive and tells the nurse, "I am afraid of going blind. It would be so hard to live that way." What factor should the nurse consider before responding to this statement? 1. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable. 2. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye. 3. More and more services are available to help newly blind people adapt to daily living. 4. Optimism is justified because surgical treatment has a 90% to 95% success rate. 4. Untreated retinal detachment results in increasing detachment and eventual blindness, but 90% to 95% of clients can be successfully treated with surgery. If necessary, the surgical procedure can be repeated about 10 to 14 days after the first procedure. Many more services are available for newly blind people, but ideally this client will not need them. Surgery does not delay blindness. Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? 1. Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks. 2. Activity level is determined by the client's tolerance; clients can be as active as they wish. 3. Activity level will be restricted for several months; the client should plan on being sedentary. 4. Activity level can return to normal; clients can resume regular aerobic exercises.
1. Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks.
The client has been diagnosed with herpes zoster (shingles). The nurse should include which information in a teaching plan? Select all that apply. 1. Instruct the client about taking antiviral agents as prescribed. 2. Demonstrate how to apply wet-to-dry dressings. 3. Explain how to follow proper hand hygiene techniques. 4. Assure the client that the pain from herpes zoster will be gone by 7 days. 5. Tell the client to remain in isolation in a bedroom until the lesions have healed.
1. Instruct the client about taking antiviral agents as prescribed. 2. Demonstrate how to apply wet-to-dry dressings. 3. Explain how to follow proper hand hygiene techniques.
After teaching the parent of a child with severe burns about the importance of specific nutritional support in burn management, which selection of foods, if chosen by the parent from the child's diet menu, indicate the need for further instruction? 1. bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks 2. cheeseburger, cottage cheese and pineapple salad, chocolate milk, and a brownie 3. chicken nuggets, orange and grapefruit sections, and a vanilla milkshake 4. beef, bean, and cheese burrito; a banana; fruit-flavored yogurt; and skim milk
1. bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks
The nurse should assess an older adult with macular degeneration for: 1. loss of central vision. 2. loss of peripheral vision. 3. total blindness. 4. blurring of vision
1. loss of central vision.
The client with Ménière's disease is instructed to modify the diet. The nurse should explain that the most frequently recommended diet modification for Ménière's disease is: 1. low sodium. 2. high protein. 3. low carbohydrate. 4. low fat.
1. low sodium.
After returning home, a client who has had cataract surgery will need to continue to instill eyedrops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The expected outcome of applying pressure is that the pressure: 1. prevents the medication from entering the tear duct. 2. prevents the drug from running down the client's face. 3. allows the sensitive cornea to adjust to the medication. 4. facilitates distribution of the medication over the eye surface.
1. prevents the medication from entering the tear duct
A client with detachment of the retina is to patch both eyes. The expected outcome of patching is to: 1. reduce rapid eye movements. 2. decrease the irritation caused by light entering the damaged eye. 3. protect the injured eye from infection. 4. minimize eye strain on the uninvolved eye.
1. reduce rapid eye movements
Which statement indicates the client understands the expected course of Ménière's disease? 1. "The disease process will gradually extend to the eyes." 2. "Control of the episodes is usually possible, but a cure is not yet available." 3. "Continued medication therapy will cure the disease." 4. "Bilateral deafness is an inevitable outcome of the disease."
2. "Control of the episodes is usually possible, but a cure is not yet available."
The client with a cataract tells the nurse about being afraid of being awake during eye surgery. Which response by the nurse would be the most appropriate? 1. "Have you ever had any reactions to local anesthetics in the past?" 2. "What is it that disturbs you about the idea of being awake?" 3. "By using a local anesthetic, you will not have nausea and vomiting after the surgery." 4. "There is really nothing to fear about being awake. You will be given a medication that will help you relax."
2. "What is it that disturbs you about the idea of being awake?"
The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out? 1. Administer morphine sulfate. 2. Administer atropine sulfate. 3. Teach deep-breathing exercises. 4. Teach leg lifts and muscle-setting exercises.
2. Administer atropine sulfate.
Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery? 1. age 75 years 2. age 30 years, with poorly controlled diabetes 3. age 55 years, with myocardial infarction 4. age 60 years, with peripheral vascular disease
2. age 30 years, with poorly controlled diabetes
What information should the nurse provide when preparing the client for tonometry? 1. Oral pain medication will be given before the procedure. 2. It is a painless procedure with no adverse effects. 3. Blurred or double vision may occur after the procedure. 4. Medication will be given to dilate the pupils before the procedure.
2. It is a painless procedure with no adverse effects.
Which goal is a priority for a client who has undergone surgery for retinal detachment? 1. Control pain. 2. Prevent an increase in intraocular pressure. 3. Cleanse the eye with soap and water. 4. Maintain a darkened environment.
2. Prevent an increase in intraocular pressure.
Eardrops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, what should the nurse do? 1. Have the client lie on the left side. 2. Pull the auricle lobe up and back. 3. Pull the ear lobe down and back. 4. Chill the eardrops prior to administering.
2. Pull the auricle lobe up and back.
Which goal is a priority for a client who has undergone surgery for retinal detachment? 1. Control pain. 2. Prevent an increase in intraocular pressure. 3. Cleanse the eye with soap and water. 4. Maintain a darkened environment. 2. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal. Control of pain with analgesics is a secondary goal. The client should avoid getting soap and water in the eye when bathing. Maintaining a darkened environment is not necessary for this client. A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" The nurse's reply should be based on the knowledge that COAG: 1. results from chronic eye inflammation. 2. causes increased intraocular pressure. 3. leads to detachment of the retina. 4. is caused by decreased blood flow to the retina.
2. causes increased intraocular pressure.
The nurse observes the client instill eyedrops. The client says, "I just try to hit the middle of my eyeball so the drops do not run out of my eye." The nurse explains to the client that this method may cause: 1. scleral staining. 2. corneal injury. 3. excessive lacrimation. 4. systemic drug absorption.
2. corneal injury
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid: 1. lying supine. 2. coughing. 3. deep breathing. 4. ambulation.
2. coughing
When caring for a child with moderate burns from the waist down, what should the nurse do when positioning the child? 1. Place the child in a position of comfort. 2. Allow the child to lie on the abdomen. 3. Ensure the application of leg splints. 4. Have the child flex the hips and knees.
3. Ensure the application of leg splints
The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information? 1. Stand in front of the client, and slowly explain the instructions. 2. Provide instructions to the spouse, and have the spouse explain them to the client. 3. Give the client written material to read, and follow up with time for questions. 4. Show the client a DVD with instructions.
3. Give the client written material to read, and follow up with time for questions.
What should the nurse instruct the client with tinea capitis to do? Select all that apply. 1. Place a dressing saturated with vinegar and water on the area. 2. Apply topical antibacterial ointment to the area. 3. Shampoo hair two or three times with selenium sulfide shampoo. 4. Use antibacterial soap for bathing. 5. Take antifungal medication as prescribed.
3. Shampoo hair two or three times with selenium sulfide shampoo. 5. Take anti fungal medication as prescribed
Sensorineural hearing loss results from which condition? 1. presence of fluid and cerumen in the external canal 2. sclerosis of the bones of the middle ear 3. damage to the cochlear or vestibulocochlear nerve 4. emotional disturbance resulting in a functional hearing loss
3. damage to the cochlear or vestibulocochlear nerve.
The nurse is admitting a client with glaucoma. The client brings prescribed eyedrops from home and insists on using them in the hospital. The nurse should: 1. allow the client to keep the eyedrops at the bedside and use as prescribed on the bottle. 2. place the eyedrops in the hospital medication drawer and administer as labeled on the bottle. 3. explain to the client that the healthcare provider (HCP) will write a prescription for the eyedrops to be used at the hospital. 4. ask the client's wife to assist the client in administering the eyedrops while the client is in the hospital.
3. explain to the client that the healthcare provider (HCP) will write a prescription for the eyedrops to be used at the hospital.
A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma: 1. frequently resolves without treatment. 2. is typically treated with sustained bed rest. 3. is a medical emergency that can rapidly lead to blindness. 4. is most commonly treated with steroid therapy.
3. is a medical emergency that can rapidly lead to blindness
To ensure safety for a hospitalized blind client, the nurse should: 1. require that the client has a sitter for each shift. 2. request that the client stays in bed until the nurse can assist. 3. orient the client to the room environment. 4. keep the side rails up when the client is alone.
3. orient the client to the room environment.
A client has a history of macular degeneration. While in the hospital, the priority nursing goal will be to: 1. provide education regarding community services for clients with adult macular degeneration (AMD). 2. provide health care related to monitoring the eye condition. 3. promote a safe, effective care environment. 4. improve vision.
3. promote a safe, effective care environment.
A client uses timolol maleate eyedrops. The expected outcome of this drug is to control glaucoma by: 1. constricting the pupils. 2. dilating the canals of Schlemm. 3. reducing aqueous humor formation. 4. improving the ability of the ciliary muscle to contract.
3. reducing aqueous humor formation.
An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element? 1. protein 2. potassium 3. fluids 4. sodium
4. sodium
The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? 1. "Place your head between your knees." 2. "Concentrate on rhythmic deep breathing." 3. "Close your eyes tightly." 4. "Assume a reclining or flat position."
4. "Assume a reclining or flat position."
A client who is prescribed by the healthcare provider (HCP) to take aspirin daily in order to prevent thrombus formation reports having ringing in the ears. The nurse advises the client to take which measure? 1. Increase fluid intake. 2. Stop taking the aspirin. 3. Use acetaminophen instead. 4. Contact the HCP.
4. Contact the HCP.
The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for: 1. paralytic ileus. 2. gastric distention. 3. hiatal hernia. 4. Curling's ulcer.
4. Curling's ulcer
An older adult takes two 81-mg aspirin tablets daily to prevent a heart attack. The client reports having a constant "ringing" in both ears. How should the nurse respond to the client's comment? 1. Tell the client that "ringing" in the ears is associated with the aging process. 2. Refer the client to have a Weber test. 3. Schedule the client for audiometric testing. 4. Explain to the client that the "ringing" may be related to the aspirin.
4. Explain to the client that the "ringing" may be related to the aspirin
To approach a deaf client, what should the nurse do first? 1. Knock on the room's door loudly. 2. Close and open the vertical blinds rapidly. 3. Talk while walking into the room. 4. Get the client's attention
4. Get the client's attention
The client is diagnosed with a detached retina in the right eye. What should the nurse do first? 1. Apply compresses to the eye. 2. Instruct the client to lie prone. 3. Remove all bed pillows. 4. Promote measures that limit mobility.
4. Promote measures that limit mobility.
The nurse should assess clients with chronic open-angle glaucoma (COAG) for: 1. eye pain. 2. excessive lacrimation. 3. colored light flashes. 4. decreasing peripheral vision.
4. decreasing peripheral vision.
After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which postoperative complication? 1. detached retina 2. prolapse of the iris 3. extracapsular erosion 4. intraocular hemorrhage
4. intraocular hemorrhage
115. The nurse should teach the client with erectile dysfunction (ED) to alter his lifestyle to: a. avoid alcohol b. follow a low-salt diet c. decreased smoking d. increase attempts at sexual intercourse
a. avoid alcohol
58. A nurse is planning care for a 25-year-old female client who has just been diagnosed with human immunodeficiency virus (HIV) infection. The client asks the nurse, "How could this have happened?" The nurse responds to the question based on the most frequent mode of HIV transmission, which is a. hugging an HIV-positive sexual partner without using barrier precautions b. inhaling cocaine c. sharing food utensils with an HIV-positive person without proper cleaning of the utensils. d. having sexual intercourse with an HIV-positive person without using a condom
d. having sexual intercourse with an HIV-positive person without using a condom
A 10-year-old has just spilled hot liquid on his arm, and a 4-inch (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do? 1. Keep the child warm. 2. Cover the burned area with an antibiotic cream. 3. Apply cool water to the burned area. 4. Call 911 to transport the child to the hospital.
3. apply cool water to the burned area
113. A male client reports having impotence. The nurse examines the client's medication regimen and determines that a contributing factor to impotence could be a. aspirin b. antihypertensives c. non steroidal anti-inflammatory drugs d. anticoagulants
b. antihypertensives
60. Women who have human papillomavirus (HPV) are at risk for development of a. sterility b. cervical cancer c. uterine fibroid tumors d. irregular menses
b. cervical cancer
A 5-year-old child brought to the clinic with several superficial sores on the front of the left leg is diagnosed with impetigo. Which instructions should the nurse give the parent? 1. Wash the child's legs once a day with a mild soap. 2. Cover the sores with loose gauze. 3. Allow the child to go back to school after 24 hours of treatment. 4. Have the child return to the clinic the next week for a follow-up examination
3. Allow the child to go back to school after 24 hours of treatment
The nurse is to administer an antibiotic to a client with burns, but there is no medication in the client's medication box. What should the nurse do first? 1. Inform the unit's shift coordinator. 2. Contact the client's healthcare provider (HCP). 3. Call the pharmacy department. 4. Borrow the medication from another client.
3. Call the pharmacy department.
46. The nurse should specifically assess a client with prostatic hypertrophy for: a. voiding at less frequent intervals b. difficulty starting the flow of urine c. painful urination d. increased force of the urine stream
b. difficulty starting the flow of urine
There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. 1. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) 2. a 20-year-old who inhaled the smoke of the fire 3. a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area [BSA]) 4. a 30-year-old with second-degree burns on the back of the left leg (about 9% of body surface area [BSA]) 5. a 40-year-old with second-degree burns on the right arm (about 10% of BSA)
1. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) 2. a 20-year-old who inhaled the smoke of the fire 3. a 50-year-old diabetic with first and second-degree burns on the left forearm (about 5% of the body surface area BSA)
The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month, five clients were diagnosed with pressure ulcers. The nurse manager should: 1. use benchmarking procedures to compare the findings with other nursing units in the hospital. 2. ask the staff education department to conduct an educational session about preventing pressure ulcers. 3. institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. 4. conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.
3. institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes
Which client should receive a shingles vaccine? A client who: 1. has never had chickenpox. 2. is at risk for genital herpes. 3. is over 60 years of age. 4. has a compromised immune system.
3. is over 60 years of age.
3. A client is prescribed oral metronidazole for treatment of bacterial vaginosis. What should the nurse instruct the client to avoid during treatment and for 24 hours thereafter? a. douching b. sexual intercourse c. hot tub baths 4. alcohol consumption
4. alcohol consumption
During the early phase of burn care, the nurse should assess the client for: 1. hypernatremia. 2. hyponatremia. 3. metabolic alkalosis. 4. hyperkalemia.
4. hyperkalemia
59. A client with human immunodeficiency virus (HIV) infection is taking zidovudine (AZT). The expected outcome of AZT is to a. destroy the virus b. enhance the body's antibody production c. slow replication of the virus d. neutralize toxin produced by the virus
c. slow replication of the virus
5. A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan? a. use a barrier method of birth control for the rest of your cycle b. you should stop taking the oral contraceptives while taking the antibiotic c. call your healthcare provider for increased hunger or fluid retention d. take the antibiotics 2 hours after the oral contraceptive
a. use a barrier method of birth control for the rest of your cycle
43. The nurse is providing preoperative instructions to a client who is having a transurethral resection of the prostate. The nurse should tell the client: a. "You will have a central venous access inserted just prior to the procedure." b. "Plan on being in the hospital anywhere from 5 to 7 days following the procedure." c. "You will be taught care of the incision and suture line prior to your discharge home." d. "Expect blood in your urine in the first couple of days following the procedure."
d. "Expect blood in your urine in the first couple of days following the procedure."
97. A client has a testicular nodule that is highly suspicious for testicular cancer. A laboratory test that supports this diagnosis is: a. decreased alpha fetoprotein (AFP) b. decreased beta-human chorionic gonadotropin (hCG) c. increased testosterone d. increased AFP
d. increased AFP
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? 1. serum creatinine level of 2.5 mg/dL (221 μmol/L) 2. little fluctuation in daily weight 3. hourly urine output of 60 mL 4. serum albumin level of 3.8 mg/dL (38 g/L)
1. serum creatinine level of 2.5 mg/dL (221mol/L)
When teaching an adolescent with facial acne about skin care, the nurse should instruct the adolescent to: 1. wash the face twice a day with mild soap and water. 2. remove whiteheads and comedones after washing the face with antibacterial soap. 3. apply vitamin E ointment twice daily to the affected skin. 4. apply tretinoin daily in the morning and expose the face to the sun.
1. wash the face twice a day with mild soap and water
Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: 1. electrical burns of the hands and arms causing arrhythmias. 2. thermal burns to the head, face, and airway resulting in hypoxia. 3. chemical burns on the chest and abdomen. 4. secondhand smoke inhalation.
2. thermal burns to the head, face, and airway resulting in hypoxia
A priority for nursing care for an older adult who has pruritus, is continuously scratching the affected areas, and demonstrates agitation and anxiety regarding the itching is: 1. preventing infection. 2. instructing the client not to scratch. 3. increasing fluid intake. 4. avoiding social isolation.
1. preventing infection
An older adult has several ecchymotic areas on the left arm. The nurse should further assess the client for (select all that apply): 1. elder abuse. 2. self-inflicted injury. 3. increased capillary fragility and permeability. 4. increased blood supply to the skin. 5. shingles
1. elder abuse 2. self-inflicted injury 3. increased capillary fragility and permeability
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Round your answer to a whole number. ________________________ mL/h
250ml
67. An 18-year-old female is to have a pelvic exam. Which response by the nurse would be best when the client says that she is nervous about the upcoming pelvic examination? a. "Can you tell me more about how you are feeling?" b. "You are not alone. Most women feel uncomfortable about this examination." c. "Do not worry about Dr. Smith. He is a specialist in female problems." d. "We will do everything we can to avoid embarrassing you."
a. "Can you tell me more about how you are feeling?"
57. What is most important information for the nurse to teach a client newly diagnosed with genital herpes? a. Use condoms at all times during sexual intercourse. b. A urologist should be seen only when lesions occur. c. Oral sex is permissible without a barrier d. Determine if your partner has received a vaccine against herpes.
a. Use condoms at all times during sexual intercourse.
39. An adult male client has been unable to void for the past 12 hours. The best method for the nurse to use when assessing for bladder distention in a male client is to check for a. a rounded swelling above the pubis b. dullness in the lower left quadrant. c. rebound tenderness below the symphysis. d. urine discharge from the urethral meatus.
a. a rounded swelling above the pubis
96. The nurse is assessing a client's testes. Which finding indicates the testes are normal? a. soft b. egg-shaped c. spongy d. lumpy
b. egg-shaped
52. An unlicensed assistive personnel (UAP) tells the nurse, "I think the client is confused. He keeps telling me he has to void, but that is not possible because he has a catheter in place that is draining well." The nurse should tell the UAP: a. "His catheter is probably plugged. I will irrigate it." b."That is a common problem after prostate surgery. The client only imagines the urge to void." c. "The urge to void is usually created by the large catheter, and he may be having some bladder spasms." d. "I think he may be somewhat confused."
c. "The urge to void is usually created by the large catheter, and he may be having some bladder spasms."
75. The nurse is caring for a client from Southeast Asia who has HIV/AIDS. The client does not speak or comprehend the English language. What should the nurse do? a. contact the hospital's chaplain b. do an internet search for the Joint United Nations Programme on HIV/AIDS c. Utilize language appropriate interpreters d. Ask a family member to obtain informed consent
c. Utilize language appropriate interpreters
64. The typical chancre of syphilis appears as: a. a grouping of small, tender, pimples b. an elevated wart c. a painless, moist ulcer d. an itching, crusted area
c. a painless, moist ulcer
95. When teaching a client to perform testicular self-examination, the nurse explains that the examination should be performed: a. after intercourse b. at the end of the day c. after a warm bath or shower d. after exercise
c. after a warm bath or shower
69. Which group has experienced the greatest rise in the incidence of sexually transmitted diseases (STDs) over the past two decades? a. teenagers b. divorced people c. young married couples d. older adults
a. teenagers
A stage II pressure ulcer is characterized by: 1. redness in the involved area. 2. muscle spasms in the involved area. 3. pain in the involved area. 4. tissue necrosis in the involved area
3. pain in the involved area
49. A client with benign prostatic hypertrophy (BPH) is being treated with terazosin 2 mg at bedtime. The nurse should monitor the client's: a. urine nitrites b. white blood cell count c. blood pressure d. pulse
c. blood pressure
45. When caring for a client with a history of benign prostatic hypertrophy (BPH), what should the nurse do? Select all that apply. a. provide privacy and time for the client to void b. monitor I&O c. catheterize the client for postpaid residual urine d. ask the client if he has urinary retention e. test the urine for hematuria
a. provide privacy and time for the client to void b. monitor I&O d. ask the client if he has urinary retention e. test the urine for hematuria
7. A nurse is caring for a hospitalized 22-year-old female client with type 1 diabetes mellitus and toxic shock syndrome (TSS). Which action should the nurse perform first? a. administer 5% dextrose in half-normal saline solution at 150ml/hr b. administer 50mg of meperidine IM every 4 hours as needed for pain c. teach the client to use pads at night instead of tampons during her menstrual period d. administer 400mg of ciprofloxacin IV every 12 hours infused over 1 hour
a. administer 5% dextrose in half-normal saline solution at 150ml/hr
61. The primary reason that a herpes simplex virus (HSV) infection is a serious concern to a client with human immunodeficiency virus (HIV) infection is that it a. is an acquired immunodeficiency virus (AIDS)- defining illness b. is curable only after 1 year of antiviral therapy c. leads to cervical cancer d. causes severe electrolyte imbalances
a. is an acquired immunodeficiency virus (AIDS)- defining illness
26. A 70-year-old client asks the nurse if she needs to have a mammogram. Which is the nurse's best response? a. "Having a mammogram when you are older is less painful." b. "The incidence of breast cancer increases with age." c. "We need to consider your family history of breast cancer first." d. "It will be sufficient if you perform breast examinations monthly."
b. "The incidence of breast cancer increases with age."
112. The client is taking sildenafil orally for erectile dysfunction. What instruction should the nurse give the client? a. Sildenafil may be taken more than one time per day b. The healthcare provider (HCP) should be notified promptly if the client experiences sudden or diminished vision. c. Sildenafil offers protection against some sexually transmitted diseases (STDs). d. Sildenafil does not require sexual stimulation to work.
b. The healthcare provider (HCP) should be notified promptly if the client experiences sudden or diminished vision.
99. Risk factors associated with testicular malignancies include: a. African race b. residing in a rural area c. lower socioeconomic status. age older than 40 years
b. residing in a rural area
56. A client with benign prostatic hypertrophy (BPH) has an elevated prostate-specific antigen (PSA) level. The nurse should a. instruct the client to request having a colonoscopy before coming to conclusions about the PSA results b. instruct the client that a urologist will monitor the PSA level biannually when elevated. c. determine if the prostatic palpation was done before or after the blood sample was drawn. d. ask the client if he emptied his bladder before the blood sample was obtained.
c. determine if the prostatic palpation was done before or after the blood sample was drawn.
6. client is asking for information about using an intrauterine device (IUD). Which question when asked by the nurse would provide pertinent information on whether or not a client is a candidate for an IUD? a. do you smoke b. do you have HTN c. how often do you have sex d. are you in a monogamous relationship
d. are you in a monogamous relationship
What should the nurse instruct a client who has cerumen buildup in the ear to do? Select all that apply. 1. Wash the external ear with a washcloth. 2. Instill cerumenolytic drops in the ear canal. 3. Use cotton-tipped applicators to remove the wax from the ear canal. 4. Use small forceps to extract the wax. 5. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.
1. Wash the external ear with a wash cloth 2. Instill cerumenolytic drops in the ear canal. 5. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.
Which complications can occur following cataract surgery? Select all that apply. 1. acute bacterial endophthalmitis 2. retrobulbar hemorrhage 3. rupture of the posterior capsule 4. suprachoroidal hemorrhage 5. vision loss
1. acute bacterial endophthalmitis 5. vision loss
The nurse has been assigned to a client who is hearing impaired and reads speech. Which strategies should the nurse incorporate when communicating with the client? Select all that apply. 1. Avoid being silhouetted against strong light. 2. Do not block out the person's view of the speaker's mouth. 3. Face the client when talking. 4. Have bright light behind so the individual can see. 5. Ensure the client is familiar with the subject material before discussing. 6. Talk to the client while doing other nursing procedures.
1. Avoid being silhouetted against strong light. 2. Do not block out the person's view of the speaker's mouth. 3. Face the client when talking 5. Ensure the client is familiar with the subject matter before discussing.
Which complications can occur following cataract surgery? Select all that apply. 1. acute bacterial endophthalmitis 2. retrobulbar hemorrhage 3. rupture of the posterior capsule 4. suprachoroidal hemorrhage 5. vision loss 1,5. Acute bacterial endophthalmitis can occur in about 1 out of 1,000 cases. Organisms that are typically involved include Staphylococcus epidermidis, Staphylococcus aureus, and Pseudomonas and Proteus species. Vision loss is one result of acute bacterial infection. In addition, vision loss can be the result of malposition of the intraocular lens implant or opacification of the posterior capsule. Retrobulbar hemorrhage is a complication that may occur right before surgery and is a result of retrobulbar infiltration of anesthetic agents. Rupture of the posterior capsule and suprachoroidal hemorrhage are both complications that can result during surgery. The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? 1. Remain in a semi-Fowler's position. 2. Position the feet higher than the body. 3. Lie on the operative side. 4. Place the head in a dependent position.
1. Remain in semi-Fowler's position.
A client has vertigo. Which goal would be most appropriate to prevent injury related to altered immobility and gait disturbances? Select all that apply. 1. The client assumes a safe position when dizzy. 2. The client experiences no falls. 3. The client performs vestibular/balance exercises. 4. The client demonstrates family involvement. 5. The client keeps the head still when dizzy.
1. The client assumes a safe position when dizzy. 2. The client experiences no falls. 3. The client performs vestibular/balance exercises. 5. The client keeps the head still when dizzy.
A 75-year-old client who has been taking furosemide regularly for 4 months tells the nurse about having trouble hearing. What should the nurse do? 1. Tell the client that at age 75 years, it is inevitable that there will be hearing loss. 2. Report the hearing loss to the healthcare provider (HCP). 3. Schedule the client for audiometric testing and a hearing aid. 4. Tell the client that the hearing loss is only temporary; when the body adjusts to the furosemide, hearing will improve.
2. Report the hearing loss to the health care provider (HCP).
The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. The nurse should assess the client further for: 1. dementia. 2. hearing loss. 3. anger. 4. depression.
2. hearing loss.
The nurse is assisting a client who has new-onset vision loss to transition to home from the hospital. The client can see shadow and light in the right eye only. When at home, the client is at greatest risk for: 1. loss of sensory perception. 2. injury from falls. 3. denial of changes in vision. 4. isolation from social activities.
2. injury from falls.
The client with retinal detachment in the right eye is extremely apprehensive and tells the nurse, "I am afraid of going blind. It would be so hard to live that way." What factor should the nurse consider before responding to this statement? 1. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable. 2. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye. 3. More and more services are available to help newly blind people adapt to daily living. 4. Optimism is justified because surgical treatment has a 90% to 95% success rate.
4. Optimism is justified because surgical treatment has a 90% to 95% success rate.
Which measure should the nurse teach the client with adult macular degeneration (AMD) as a safety precaution? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4. Turn the head from side to side when walking.
4. Turn the head from side to side when walking.
40. When emptying the client's bladder during a urinary catheterization, the nurse should allow the urine to drain from the bladder slowly to prevent: a. renal failure b. abdominal cramping c. possible shock d. atrophy of bladder musculature
c. possible shock
4. A female client with which condition would be at risk for increased severity of vulvovaginal candidiasis? Select all that apply. a. uncontrolled diabetes b. immunosuppression due to cancer c. human immunodeficiency virus (HIV infection) d. hypertension e. asthma
a. uncontrolled diabetes b. immunosuppression due to cancer c. human immunodeficiency virus (HIV infection)
25. The client states that she has noticed that her bra fits more snugly at certain times of the month. She asks the nurse if this is a sign of breast disease. The nurse should base the reply to this client on the knowledge that: a. benign cysts tend to cause the breasts to vary in size b. it is normal for the breasts to increase in size before menstruation begins 3. a change in breast size warrants further investigation 4. differences in breast size are related to normal growth and development
b. it is normal for the breasts to increase in size before
114. A 65-year-old male client with erectile dysfunction (ED) asks the nurse, "Is all this just in my head? Am I crazy?" The best response by the nurse is based on the knowledge that: a. ED is believed to be psychogenic in most cases b. more than 50% of the cases are attributed to organic causes c. evaluation of nocturnal erections does not help differentiate psychogenic or organic causes d. ED is an uncommon problem among men older than age 65
b. more than 50% of the cases are attributed to organic causes
100. A client with a testicular malignancy undergoes a radical orchiectomy. In the immediate postoperative period, the nurse should particularly assess the client for: a. bladder spasms b. urine output c. pain d. nausea
c. pain
94. A 30-year-old client is being treated for epididymitis. Teaching for this client should include the fact that epididymitis is commonly a result of a a. virus b. parasite c. sexually transmitted infection d. protozoon
c. sexually transmitted infection
