medsurge2 week 6

Which of the following brain structures is responsible for equilibrium?

Cerebellum

A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following?

Chlamydia trachomatis

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?

Conduction

An initial, convenient assessment of an elderly patient's complaint of hearing loss would be inspection, using an otoscope, for the presence of impacted cerumen. Which of the following is a primary cause of an external ear disorder in the elderly?

Conduction problem

During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as:

Conductive.

Which of the following secondary skin lesions are associated with eczema?

Crusts

What type of medication would the nurse use in combination with mydriatics to dilate the patient's pupil?

Cycloplegics

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?

"Have you been eating a large amount of carotene-rich foods?"

A client asks the nurse what they can do to improve their vision after having their cataract removed. What is the nurse's best response?

"Having an intraocular lens implanted at the time of surgery is the best thing you can do."

Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis?

"My eyelids were stuck together this morning."

The nurse is precepting a nursing student when a new client comes to the eye clinic. The client explains that they think they have a corneal abrasion. The nurse should explain what to the student nurse?

"To detect corneal abrasions, a slit lamp is used."

A 52-year-old woman comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate?

"You'll need to use the drops for the rest of your life to control the glaucoma."

Which of the following teaching points would a nurse include as postoperative instructions for patients who have had middle ear surgery? Select all that apply.

-Blow the nose gently, one side at a time, for 7 days after surgery. -Report excessive ear drainage to the health care provider. -Avoid getting water in the ear for 14 days after surgery. -Avoid lifting more than 10 pounds for a few weeks after surgery.

The ophthalmologist tells a patient that he has increased intraocular pressure (IOP). The nurse understands that increased pressure, resulting from optic nerve damage, is indicated by a reading of:

>21 mm Hg.

Which of the following describes vertigo? Select all that apply.

-Misperception of motion -Objects are moving around him or her -Spinning sensation

Which of the following are methods of removing foreign bodies from the ear? Select all that apply.

-Suction -Instrumentation -Irrigation

When evaluating fluid balance in a patient with a fever, the nurse estimates insensible fluid loss. A loss of 1,000 mL/24 hours can occur with a temperature of:

103.5°F

A client is receiving phenylephrine eye drops in preparation for ophthalmoscopy. The client receives the final dose of drops at 10:30 a.m. The nurse informs the client that he will begin to notice the effects of the drug beginning to wear off around what time?

1:30 p.m.

A client who wears soft contact lenses opts for laser correction surgery. The nurse would instruct the client to discontinue using the contact lenses for which time period before surgery?

2- 3 weeks

It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye?

20/200

When undergoing testing of visual acuity with a Snellen chart, the client can read the line labeled 20/50 but misses three letters on the line. The nurse documents this finding as which of the following?

20/50-3

A patient is suspected of having glaucoma. What reading of IOP would demonstrate an increase resulting from optic nerve damage?

21 mm Hg or higher

A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?

25 mm Hg

A nurse practitioner checks pupillary response with a penlight. The nurse is aware that the normal pupil size in room lighting is:

3-5mm

Louisa Travis, a 22-year-old hand model, cut her hand on a broken glass while washing dishes and arrived at the ED where you practice nursing applying pressure to her bleeding hand. The ED physician sutured her wound and you are in the process of communicating her discharge instructions to her. She asks how long it will take for her sutures to completely heal. What is your answer?

35 - 45 days

A nurse is asked to assess a patient's need for a hearing aid. The nurse knows that a general guideline to determine need would be a hearing loss of:

40 dB in the range of 500 to 2,000 Hz.

During testing with a Snellen chart, the nurse learns that a client sees at 20 feet what most clients see at 50 feet. How would the nurse record the client's visual acuity? Fill in the blank: 20/

50

You are doing hearing tests at the local junior high school. Which child has normal hearing acuity?

A client who first perceives sound at 20 dB

Which of the following preattack symptoms may a patient with Meniere's disease report prior to an attack?

A full feeling in the ear

A patient comes to the clinic with a suspected eye infection. The nurse recognizes that the patient most likely has conjunctivitis, as evidenced by what symptom?

A mucopurulent ocular discharge

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing

A patient is complaining of ringing in the left ear and hearing loss in the same ear, but does not have any associated dizziness or vertigo. What should this patient be assessed for?

Acoustic neuroma

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

Acute angle-closure

Which type of glaucoma presents an ocular emergency?

Acute angle-closure glaucoma

A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of?

Adhere to the medication regimen.

Which of the following describes a total absence of pigment melanin?

Albinism

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?

Amsler grid

A patient is being assessed for a vision problem. The nurse notes unequal pupils. The nurse would document this finding as which of the following?

Anisocoria

Which of the following terms refers to the absence of the natural lens?

Aphakia

High doses of this medication can produce bilateral tinnitus?

Aspirin

A client who is legally blind comes to the eye clinic for a routine examination. What is a parameter of assessment that the nurse should cover in this client?

Assess how the client is coping with their visual problems.

You are caring for a client who is post-stapedectomy. What would you include in your nursing care?

Assessment of the facial nerve.

A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home?

Avoid bending the head below the waist.

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?

BUN and creatinine

A client you are caring for has a hearing loss. The client tells you they are self-conscious about their hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his or her self-esteem?

Be forthright and inform others about the hearing deficit.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line

A nurse instructs a client to refrain from blinking after administering eye drops based on which rationale?

Blinking causes the eye drop to be expelled from the conjunctival sac.

The physician suggests that a client use meclizine as treatment for his motion sickness. The nurse explains the rationale for this drug based on an understanding of which of the following as the drug's action?

Blocks conduction of the vestibular pathways

The nurse is administering an ophthalmic ointment to a patient with conjunctivitis. What disadvantage of the application of an ointment does the nurse explain to the patient?

Blurred vision results after application.

The nurse is performing the test shown in the accompanying image. What is the nurse attempting to evaluate?

Bone conduction of sound

The nurse is assessing the skin of an older adult patient. Which of the following would the nurse identify as abnormal?

Bulla

Chemical burns of the eye are immediately treated by:

Flushing the lids, conjunctiva, and cornea with tap water or normal saline.

When the nurse is examining the fundus, a yellow lipid may present in the retina of the patient diagnosed with which of the following?

Diabetes

Health teaching for a patient who suffers from motion sickness would include recommending the use of which one of the following over-the-counter drugs?

Dramamine

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

Eustachian tube

A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high?

Evaporation

A nures is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?

External auditory canal erythema

The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?

Extraocular muscle function

People with hyperopia are considered which of the following?

Farsighted

The nurse should monitor for which of the following manifestations in a patient who has undergone LASIK?

Halos and glare

Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color?

Hemangioma

A client has undergone enucleation. What complication of enucleation should be addressed by the nurse?

Hemorrhage

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?

Herpes zoster

Leslie Waterman, a 57-year-old corrections officer, is being seen at the ophthalmic group where you practice nursing. He's concerned about his vision changes where he sees distance much more clearly than nearby sights. What is the term used to describe his visual condition?

Hyperopia

Which layer of the skin is made of primarily adipose tissue?

Hypodermis

Production of melanin is controlled by a hormone secreted by which of the following?

Hypothalamus

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?

Hypoxia

During a neurological physical examination, a patient tells the nurse that she is having difficulty raising her right eyelid. The nurse knows that this may be an indication of problems with which cranial nerve?

III

A patient's range of hearing loss is diagnosed as "mild-moderately severe." The nurse knows that the audiologist would recommend which of the following hearing aid sites?

In the canal

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

Inner ear

A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear?

Instillation of mineral oil

A nursing instructor is teaching pre-nursing students in a pathophysiology class. What would the instructor teach the students about Ménière's disease?

It is referred to as endolymphatic hydrops.

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?

Keloid

Which of the following surgical procedures involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?

LASIK

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification

The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care?

Limit foods that are high in sodium.

A patient is participating in aural rehabilitation. The nurse understands that this type of training emphasizes which of the following?

Listening skills

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:

Loss of accommodative power in the lens.

Which of the following is a factor that causes wrinkles among older adults?

Loss of the subcutaneous tissue

A client comes to the eye clinic for an examination. The client tells the nurse that their vision is like a target with the bull's eye area of the image missing. What would the nurse suspect?

Macular degeneration

Which of the following is the most common cause of visual loss in people older than 60 years of age?

Macular degeneration

Hearing aids help with which of the following problems?

Makes sounds louder

The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?

Marked blurring of vision

The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack?

Meclizine (Antivert)

Which of the following pigments influences hair color?

Melanin

A client comes to the emergency department, reporting that a bee has flown into his ear and is stuck. The client reports a significant amount of pain. Which of the following would be most appropriate to use to remove the bee?

Mineral oil

Central cyanosis is best reflected in which of the following locations?

Mucous membranes

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?

Myopia

To avoid the side effects of corticosteroids which medication classification is used as an alternative to treating inflammatory conditions of the eyes?

NSAIDS

When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease?

Purplish cutaneous lesions

Which of the following is an involuntary rhythmic movement of the eyes that is also associated with vestibular dysfunction?

Nystagmus

The nurse recognizes that the tool used to examine the inside of the eyes and shown in the accompanying image is called the

Ophthalmoscope

The point at which the optic nerve leaves the eye and meets the optic nerve from the other eye is which of the following?

Optic chiasm

A 63-year-old client has developed diabetic retinopathy and is seeing the physician regularly to prevent further loss of sight. From where do the nerve cells of the retina extend?

Optic nerve

To detect cyanosis in persons with dark skin, the nurse should assess which of the following areas?

Oral mucosa

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?

Otosclerosis

A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?

Patch test

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely?

Patch testing

A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client?

Patchy flakes clinging to the eyelashes

Surgery

Patient will experience no falls due to balance disorder.

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate?

Presbyopia

A 15-year-old pubescent boy is visiting a primary care group for a sports physical for high school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with his age. What is the primary function of sebum?

Prevents drying, cracking of skin and hair

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder

Prolonged use of corticosteroids

A nurse conducting a session on eye care needs to educate clients about the aqueous humor and vitreous humor. Which is the function of the aqueous humor?

Provides nutrients and oxygen to the cornea

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have?

Psoriasis

A nurse is caring for an elderly client who complains that she is unable to read a newspaper or a magazine properly, even in normal light. Which is the most likely cause for this condition?

Pupil is no longer able to dilate fully.

As a nurse practicing within a pediatric medicine group, you take your role quite seriously in preserving children's hearing and preventing hearing loss in your clients. What can you do to maintain hearing within your client base?

Reduce frequency and severity of ear infections

An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition?

Reduction in sebum production

Which of the following is an accurate statement regarding refractive surgery?

Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea.

Which of the following tests use a tuning fork between two positions to assess hearing?

Rinne's

Which diagnostic test distinguishes between conductive and sensorineural hearing loss?

Rinne's test

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?

Risk for injury related to vertigo

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear?

Scleral buckle

The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has?

Seborrheic dermatitis

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision

Sees an object from 20 feet away that a person with normal vision sees from 200 feet away.

Postoperative nursing assessment for a patient who has had a mastoidectomy should include observing for facial paralysis, which might indicate damage to which cranial nerve?

Seventh

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion?

Spider angioma

A nurse completes assessment of the skin of an 82-year-old resident in a nursing home. She notices the presence of multiple dilated capillaries radiating from a central arteriole. The nurse documents their presence on the electronic health record as:

Spider angiomas.

A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do?

Stand about 1 to 2 feet away from the ear to be tested.

Which of the following occurs when there is deviation from perfect ocular alignment?

Strabismus

Which portion of the skin is primarily composed of connective tissue and fat cells?

Subcutaneous tissue

Which of the following is the treatment of choice for acoustic neuromas?

Surgery

A client comes to the walk-in clinic complaining of an earache. The cause is found to be impacted cerumen. The client asks the nurse what they can do at home to soften hardened cerumen. What should the nurse recommend to a client to soften hardened cerumen?

Take nonprescription preparations.

A client with glaucoma has been given a prescription for a mydriatic drug. What is a priority action of the nurse?

Tell the physician.

The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment?

The power of the lens to accommodate will be decreased.

A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign?

The presence of halos around lights

The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?

The skin is ashen gray and dull.

A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure (IOP) with a tonometer. Which statement about this procedure is true?

The tonometer will register the force required to indent or flatten the corneal apex.

You are teaching a parent how to instill drops in their 12-year-old sons' eyes. Which action would you teach the parent is accomplished first?

Tilt the head slightly backward.

During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?

To prevent vision loss

The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client?

To reduce the production of fluid in the inner ear

Which portion of the middle ear equalizes pressure?

Tympanic membrane

Acoustic neuromas are benign tumors of which of the following cranial nerves?

VIII

A client is diagnosed with Meniere's disease. The nurse would most likely expect the client to report which of the following?

Vertigo

Which of the following manifestations is the most problematic for the patient diagnosed with Meniere's disease?

Vertigo

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?

Vesicle

The clinical manifestations of motion sickness are caused by an overstimulation in what system?

Vestibular

Based on knowledge about the synthesis of this vitamin, a nurse would recommend exposure of the skin to ultraviolet light on a daily basis, whenever possible. What is this vitamin?

Vitamin D

A client, in for an eye exam, asks the nurse what they can do to help prevent cataracts. What dietary recommendations should a nurse give to a client to prevent cataracts?

Vitamins A and C

Which of the following terms refers to a condition characterized by destruction of the melanocytes in circumscribed areas of the skin?

Vitiligo

A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse?

Write down the steps of the procedure for the patient to read before beginning the treatment.

Which of the following are yellowish waxy deposits on the upper and lower eyelids?

Xanthelasma

Macular degeneration is suspected in a client experiencing blurred vision when reading. The nurse performs an ophthalmoscopic examination. Which finding would the nurse identify as helping to support this suspicion?

Yellow areas with indistinct edges beneath the retina

The nurse is reading the physician's report of an elderly patient's physical examination. The patient demonstrates xanthelasma, which refers to which of the following symptoms?

Yellowish waxy deposits on upper eyelids

An 88-year-old client has a history of hearing loss and is returning for his annual hearing examination. During your client education session, you explain to the client that hearing involves which areas of the ear?

all sections

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia.

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?

bronze

A client is color blind. The nurse understands that this client has a problem with:

cones.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation.

A nurse is using the tool in the accompanying image during assessment of the sensory system. What is the nurse assessing?

far vision

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:

light flashes and floaters in front of the eye.