NU272 EAQ Evolve Elsevier NU272 HESI Prep: Med-Surg Neurologic and Sensory
While assessing the client, the nurse observes abnormal eye movement. The client reports dizziness when standing or walking. Which structure of the auditory system might be affected in this client? o A (tympanic membrane) o B (vestibular system) o C (auditory tube) o D (cochlea)
o B (vestibular system) · Abnormal eye movement is seen in nystagmus. Dizziness when standing or walking may indicate vertigo in the client. These both manifest because of problems with balance, which is maintained by the vestibular system marked by B. The structure represented as A is the tympanic membrane, a part of the middle ear. Conductive hearing loss may occur if the tympanic membrane is affected. The structure represented as C is the auditory tube, which helps equalize atmospheric air pressure between the middle ear and throat and allows the tympanic membrane to move freely. Structure C is not associated with vertigo and nystagmus. The structure represented as D is the cochlea and is involved in the transmission of sounds. Hearing impairment may result if the cochlea is affected.
Which client's tears contain mucus strands? o Client A (Dry eye syndrome with reduced tear production) o Client B (Infection of the eyelid sweat glands) o Client C (Inflammation of a sebaceous gland in the eyelid) o Client D (Turning outward and sagging of the eyelid)
o Client A (Dry eye syndrome with reduced tear production) · Client A, with reduced tear production, may experience the condition known as keratoconjunctivitis sicca, or dry eye syndrome. The side effects of this condition include dullness of the corneal light reflex and tears with mucus strands. Sensation of a foreign body in the eye, burning and itching, and photophobia are also common with this condition. Client B, with infection of the eyelid sweat glands, may experience a hordeolum, or stye, that appears as a red, swollen, painful area on the outer surface of the eyelid. Client C, with inflammation of a sebaceous gland in the eyelid, also known as a chalazion, may experience fatigue, light sensitivity, and excessive tears. Client D, with turning outward and sagging of the eyelid, also known as an ectropion, which is caused by muscle relaxation or weakness, has a condition that often occurs with aging. This position of the lid reduces the washing action of tears, leading to corneal drying and ulceration.
Which clinical indicators would the nurse expect to identify when assessing a client who has trigeminal neuralgia (tic douloureux)? Select all that apply. One, some, or all responses may be correct. o Prolonged periods of sleep o Hyperactivity o Exhaustion and fatigue o Excessive talkativeness o Inadequate nutritional intake
o Exhaustion and fatigue o Inadequate nutritional intake · Severe, constant pain; emotional stress; muscle tensing; and diminished nutritional intake can lead to exhaustion and fatigue. The movements associated with chewing and swallowing may precipitate a painful attack. Because clients are apprehensive and have pain, prolonged periods of sleep usually do not occur. Pain medications do not normally cause hyperactivity. The client may speak less for fear of precipitating an attack.
Which information, if reported by a client within 4 hours after repair of a retinal detachment, would the nurse plan to communicate to the primary health care provider? o Has not voided o Cannot open the eye o Cannot remember the date o Has sharp pain in the eye
o Has sharp pain in the eye · Reports of sharp pain in the eye indicate that hemorrhage may be occurring in the eye. Four hours is too soon to be concerned that the client has not voided. The eye would be patched; in addition, there is edema of the lid, which can interfere with opening the eye. Becoming disoriented and not remembering the date may occur in an unfamiliar environment.
After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate antidiuretic hormone (SIADH). For which clinical indicators would the nurse monitor the client? Select all that apply. One, some, or all responses may be correct. o Polyuria o Insomnia o Bradycardia o Increased weight o Decreased serum sodium o Decreased level of consciousness
o Increased weight o Decreased serum sodium o Decreased level of consciousness · As fluid is retained, the body weight will increase. One liter of fluid weighs 2.2 pounds (1 kilogram). Excess antidiuretic hormone (ADH) causes water retention, which leads to dilutional hyponatremia. Dilution of blood and hyponatremia cause a decreased level of consciousness. Water retention and decreased urinary output occur because of ADH excess. Urine output decreases to less than 20 mL/hour. This client will be lethargic, confused, or comatose, depending on the degree of hyponatremia. Tachycardia, not bradycardia, occurs in response to fluid volume excess associated with increased ADH.
A married older adult couple lives independently and has three adult children. The husband, who is alert but forgetful, has an enlarged prostate with infrequent urinary incontinence. The wife has diabetes mellitus, rheumatoid arthritis, and walks with difficulty. The nurse identified the couple's need for assistance with bathing, dressing, and meal preparation. Which option would the nurse suggest, which best meets the needs of this couple? o Admit them together to an extended care facility (nursing home). o Place them in an apartment together, within an assisted-living facility. o Keep the couple in their home and schedule assistance with a home health aide. o Encourage the couple to move in with one of their children for safety reasons
o Keep the couple in their home and schedule assistance with a home health aide. · Care provided in the home is more efficient and cost-effective; this couple can manage with assistance from community resources. There is nothing in the history to demonstrate that skilled nursing care provided by a nursing home is necessary. Because the couple appears able to function with assistance at home, it is not necessary to move them to another setting at this time.
A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. Which action would the nurse take? o Notify the health care provider. o Elevate the head of the bed. o Reduce the prescribed flow rate of intravenous (IV) fluid. o Administer the next scheduled dose of osmotic diuretic early
o Notify the health care provider. · Immediate corrective therapy based on current assessments must be implemented. After an infratentorial craniotomy the client is positioned flat on one side with the head on a small, firm pillow unless otherwise instructed by the health care provider. Administering medication or adjusting an IV rate is a dependent function of the nurse, and the prescription must be followed exactly. Changes to prescriptions may be received when the health care provider is notified.
The nurse assesses a client admitted with suspected Guillain-Barré syndrome who reports numbness, which began in the hands and feet and now involves the arms, legs, and lower trunk. For which related clinical manifestations would the nurse assess in this client? o Ptosis and dysphagia o Paresthesia and paralysis o Atrophy and fasciculations o Muscle weakness and drooling
o Paresthesia and paralysis · Guillain-Barré syndrome includes the clinical manifestations of paresthesia and paralysis result from patchy demyelination of the peripheral nerves, nerve roots, root ganglia, and the spinal cord. Ptosis and dysphagia relate to myasthenia gravis. Atrophy and fasciculations relate to amyotrophic lateral sclerosis. Muscle weakness and drooling relate to Parkinson disease.
Which expected surgical outcome would the nurse include in the preoperative teaching for a client scheduled for a labyrinthectomy to treat Meniere syndrome? o Absence of pain o Decreased cerumen o Loss of sense of smell o Permanent irreversible deafness
o Permanent irreversible deafness · The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, and other structures. A labyrinthectomy alleviates the symptoms of Meniere syndrome but results in deafness on the affected side because the organ of Corti and cochlear nerve are located in the inner ear. There is no pain associated with Meniere syndrome. Meniere syndrome does not affect the production of cerumen. The scheduled surgical procedure does not affect the sense of smell (anosmia).
The emergency department received a client who was a passenger in an automobile collision, with rhinorrhea and bleeding from their ear. Having sustained a basilar head injury, which interventions would the nurse anticipate as the initial focus of this client's care? o Physical therapy o Psychosocial support o Nutritional management o Antimicrobial administration
o Antimicrobial administration · Preventing infection is the initial priority and accomplished with the use of prophylactic antibiotics because tearing of the meninges may have introduced infectious organisms. Physical therapy is premature; physical therapy begun too early can increase intracranial pressure. Although psychosocial support is important, it is not the priority. Nutrition is not the priority at this time.
Which type of vision problem would the nurse document when a client describes being able to see near objects clearly, but objects in the distance are blurry? o Myopia o Hyperopia o Presbyopia o Astigmatism
o Myopia · This client is describing myopia, which is nearsightedness. Hyperopia is farsightedness. Presbyopia is the loss of accommodation, which causes an inability to focus on near objects. Astigmatism is an uneven curvature of the cornea, which causes distorted vision.
Which instructions would the nurse include when teaching a client with multiple sclerosis (MS) about managing urinary retention? Select all that apply. One, some, or all responses may be correct. o Using the Credé maneuver o Using an indwelling catheter o Using anticholinergic medications o Monitoring and restricting fluid intake to 800 mL daily o Monitoring for and reporting signs of urinary tract infection
o Using the Credé maneuver o Monitoring for and reporting signs of urinary tract infection · The Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with MS. Early recognition and treatment of infection are important to decrease the risk of exacerbation in the client with MS. Use of an indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary retention are taught intermittent self-catheterization. Risk of urinary tract infection is lower with intermittent catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be encouraged in the client with voiding difficulties, as concentrated urine increases the risk of urinary tract infection.