NUR 114 Final Test 1 adaptive quiz

Clients with eating disorders often exhibit similar symptoms. What should the nurse expect an adolescent with anorexia nervosa to exhibit? 1. Affective instability 2. Repetitive motor mechanisms 3. Depersonalization and derealization 4. Disheveled and unkempt physical appearance

1. Affective instability (repeated, rapid, and abrupt shifts in mood) Individuals with anorexia often display irritability, hostility, and a depressed mood. Repetitive motor mechanisms are associated with autism. Depersonalization and derealization are associated with individuals with schizophrenia. Clients with eating disorders are usually meticulous about dress and physical appearance; a disheveled appearance is associated with dementia or depression.

A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 1. 2 years 2. 6 years 3. 6 months 4. 1 to 3 months

1. 2 years By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis? 1. Sees best in dim light 2. Sees halos around lights 3. Cannot see objects in the periphery 4. Cannot see objects in the center of the visual field

4. Cannot see objects in the center of the visual field The macula is the central vision area of the retina; therefore macular degeneration affects central vision and makes it difficult to see objects within direct, central vision. Dim light will make vision more difficult for this client. Seeing halos around lights is related to glaucoma rather than to macular degeneration. An inability to see objects in the periphery is related to glaucoma rather than to macular degeneration.

A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching is effective? 1. Promote growth of new retinal cells. 2. Adhere the sclera to the choroid layer. 3. Graft a healthy piece of retina in place. 4. Create a scar that aids in healing retinal holes.

4. Create a scar that aids in healing retinal holes. Scar formation seals the hole and promotes attachment of the two retinal surfaces. The retina is part of the nervous system; it does not regenerate or grow new cells. The sclera is not involved; the retina adjoins and is nourished by the choroid. Grafting a healthy piece of retina in place is not the treatment used; treatment includes the formation of a scar by the use of lasers or surgical "buckling."

The nurse is teaching a client about caring for a hearing aid. Which statements made by the client indicates the need for further learning? Select all that apply. 1. "I should always keep my hearing aid on." 2. "I can adjust the volume of my hearing aid." 3. "I should check and replace the battery frequently." 4. "I can use hair sprays and hair oil while wearing a hearing aid." 5. "I can clean the ear mold with a soap and water with limited wetting."

1. "I should always keep my hearing aid on." 4. "I can use hair sprays and hair oil while wearing a hearing aid." A hearing aid is a small electronic amplifier which assists clients with conductive hearing loss. The hearing aid should be turned off when not in use. Hair sprays and hair oils can cause damage when they come in contact with the hearing aid. The volume of the hearing aid can be adjusted to prevent feedback squeaking. Batteries should be checked and replaced frequently. The ear mold of the hearing aid can be cleaned with soap and water; excessive wetting should be avoided.

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? 1. An increase in the pressure within the eyeball 2. An opacity of the crystalline lens or its capsule 3. A curvature of the cornea that becomes unequal 4. A separation of the neural retina from the pigmented retina

1. An increase in the pressure within the eyeball An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow. An opacity of the crystalline lens or its capsule is the description of a cataract. A curvature of the cornea that becomes unequal is the description of astigmatism. A separation of the neural retina from the pigmented retina is the description of a detached retina.

A client's relative asks the nurse what a cataract is. Which explanation should the nurse provide? 1. An opacity of the lens 2. A thin film over the cornea 3. A crystallization of the pupil 4. An increase in the density of the conjunctiva

1. An opacity of the lens A cataract is a clouding (opacity) of the crystalline lens or its capsule. A thin film over the cornea, a crystallization of the pupil, and an increase in the density of the conjunctiva are not the pathophysiology related to cataracts.

A nurse is assessing a client with chronic schizophrenia. Which effects will the client most likely exhibit? Select all that apply. 1. Apathy 2. Hostility 3. Flatness 4. Sadness 5. Happiness 6. Depression

1. Apathy 3. Flatness Apathy (indifference) is common among people with chronic schizophrenia because negative symptoms are more apparent. Flatness, with few extremes of emotion, is common among people with chronic schizophrenia because negative symptoms are more apparent. Extremes in emotions are not associated with chronic schizophrenia. Sadness is related more to mood disorders, such as a depressive episode of bipolar disorder or major depression. Hostility may be seen in some forms of schizophrenia, such as paranoid schizophrenia, but it is rarely seen in the chronic stages. Happiness and elation are associated with manic episodes of bipolar disorder, not chronic schizophrenia. Depression is related to mood disorders, such as a depressive episode of bipolar disorder or major depression.

A nurse is caring for a client who is depressed. When is the most important time for the nurse to be alert to the possibility of the client acting out suicidal thoughts? 1. As the depression lifts 2. If the depression is severe 3. When the client has recovered from the depression 4. After the client understands the cause of the depression

1. As the depression lifts As the depression lifts, the client will have more psychic and physical energy to plan and implement a suicidal act. Also, some people who decide to commit suicide feel better because they believe that relief from their psychic pain will be coming soon as a result of their decision. The thoughts, actions, and decision-making ability necessary to plan and carry out suicide are decreased during severe depression. The client most likely will not be suicidal once recovery from the depression has occurred. After the client understands the cause of the depression, the likelihood of suicide is not increased. The client's energy level and the ability to make a decision to commit suicide are more important factors to consider.

Which beta-adrenergic blocker is prescribed to clients with glaucoma? 1. Betaxolol 2. Carbachol 3. Brimonidine 4. Methazolamide

1. Betaxolol Betaxolol is a beta-adrenergic blocker that is prescribed for glaucoma. Carbachol is a cholinergic agent that is used to treat glaucoma. Brimonidine is an alpha-adrenergic agonist that is prescribed in glaucoma. Methazolamide is a carbonic anhydrase inhibitor that is used to treat glaucoma.

A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? 1. Depression 2. Dependency 3. Marital stress 4. Identity confusion

1. Depression Decreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression.

A nurse is caring for a 4-year-old child with just-diagnosed cystic fibrosis. The child has been passing loose, bulky, foul-smelling stools and is in the third percentile for weight. What is the best explanation of the growth failure? 1. Impaired digestion and absorption because of the lack of pancreatic enzymes 2. Dyspnea and shortness of breath, which cause anorexia and disinterest in food 3. Increased bowel motility and diarrhea, which lead to inadequate absorption of nutrients 4. Pulmonary obstruction, which causes an oxygen deficit and inadequate tissue nourishment

1. Impaired digestion and absorption because of the lack of pancreatic enzymes Obstruction of the pancreatic duct and the absence of enzymes (e.g., trypsin, amylase, and lipase) to aid fat digestion and absorption lead to wasting of tissues and failure to thrive. Currently it is recommended that children with cystic fibrosis consume 150% to 200% of the calories recommended for their body weight. Despite dyspnea and shortness of breath, when feeling well these children have voracious appetites; the difficulty involves poor digestion and malabsorption of fats and fat-soluble vitamins. Increased bowel motility and diarrhea are not associated with cystic fibrosis. The pulmonary disease process leads to localized respiratory dysfunction, not to retarded physical growth.

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment? 1. Inhibition of tear production 2. Inhibition of peripheral vision 3. Impairment of eye movement 4. Impairment of pupil constriction

1. Inhibition of tear production Injury to cranial nerve VII mainly leads to inhibition of tear production, a condition called keratoconjunctivitis sicca or dry eye syndrome. Any impairment to cranial nerve II may affect peripheral and central vision. Cranial nerves III, IV and VI affect eye movement. Therefore any injury to these nerves may affect eye movement. The function of cranial nerve III is constriction of the pupil. Any injury to this nerve may lead to impairment of pupil constriction.

A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? 1. Loss of central vision 2. Attacks of acute pain 3. Constant blurred vision 4. Decreased peripheral vision

1. Loss of central vision The main characteristic of dry age-related macular degeneration is loss of central vision, which is gradual. Primary closed-angle glaucoma causes pain. Blurred vision may be caused by a refractive error. Loss of peripheral vision does not occur with macular degeneration; peripheral vision loss can occur with glaucoma.

What should the nurse teach parents about childhood depression? 1. May appear as acting-out behavior 2. Looks almost identical to adult depression 3. Does not respond to conventional treatment 4. Is short in duration and has an early resolution

1. May appear as acting-out behavior Children have difficulty verbally expressing their feelings; acting-out behaviors, such as temper tantrums, may indicate an underlying depression. Many conventional therapies for adults with depression, including medication, are effective for children with depression. Adult and childhood depression may be manifested in different ways. Childhood depression is not necessarily short and requires treatment.

What clinical indicators should the nurse expect when interviewing and assessing a client with Meniere disease? Select all that apply. 1. Nausea 2. Dizziness 3. Decreased pulse rate 4. Increased temperature 5. Jerky lateral eye movements

1. Nausea 2. Dizziness 5. Jerky lateral eye movements Nausea is related to vertigo, which is associated with this disorder. The sensation of spinning (vertigo) occurs with inflammation of the inner ear. Jerky lateral eye movement (nystagmus), particularly toward the involved ear, occurs with Meniere disease. The heart rate does not decrease with this disorder. Body temperature is not influenced by this disorder.

A nurse is interviewing a child with attention deficit disorder. For which major characteristic should the nurse assess this child? 1. Overreaction to stimuli 2. Continued use of rituals 3. Delayed speech development 4. Inability to use abstract thought

1. Overreaction to stimuli A universal characteristic of children with attention deficit disorder is distractibility. They are highly reactive to any extraneous stimuli, such as noise and movement, and are unable to inhibit their responses to such stimuli. Rituals are uncommon, although these children do use repetition in language and movement. Delayed development of language skills is not the major problem, but children with attention deficit disorder may exhibit dyslexia (reading difficulty), dysgrammatism (speaking difficulty), dysgraphia (writing difficulty), or delayed speech. Loss of abstract thought is not a universal characteristic associated with children with attention deficit disorder.

What could be the reason for cataracts in a 36-year-old client? Select all that apply. 1. Prolonged exposure to heat 2. Prolonged exposure to pesticides 3. Prolonged exposure to cement dust 4. Prolonged exposure to metal powders 5. Prolonged exposure to anesthetic gases

1. Prolonged exposure to heat 4. Prolonged exposure to metal powders Glass workers are exposed to heat and metal powders for prolonged periods, which may increase their risk of developing cataracts. A prolonged exposure to pesticides may cause pesticide poisoning. Prolonged exposure to cement dust may cause bronchitis. Prolonged exposure to anesthetic gases may have reproductive effects.

The nurse is caring for a 12-month-old infant with a diagnosis of failure to thrive. The infant's weight is below the third percentile, and development is delayed. Which behaviors of the child suggest to the nurse the possibility of parental neglect? Select all that apply. 1. Stiff 2. Withdrawn 3. Easily satisfied 4. Minimal smiling 5. Responsive to touch 6. Little interest in the environment

1. Stiff 2. Withdrawn 4. Minimal smiling 6. Little interest in the environment Infants with failure to thrive resulting from parental neglect are either stiff and unyielding or flaccid and unresponsive. These infants have difficulty reaching out to the environment and tend to be withdrawn. They get little response from parents and do not learn how to respond to others. These infants show little satisfaction, are very difficult to comfort, and are nonresponsive or minimally responsive to human contact. These infants have social and language deficits and display minimal interest in the environment or others.

Which physical or behavioral signs of substance abuse should a nurse look for in an adolescent? Select all that apply. 1. Worrying about being addicted 2. Showing a high performance in social activities 3. Experiencing an overdose or withdrawal symptoms 4. Worrying about a friend or family member who is addicted 5. Manifesting bizarre behavior or confusion

1. Worrying about being addicted 3. Experiencing an overdose or withdrawal symptoms 5. Manifesting bizarre behavior or confusion Worrying of being addicted, experiencing overdose or withdrawal symptoms, and manifesting bizarre behavior may be earliest signs of substance abuse. Showing high performance in social activities and worry about a friend or family member's substance abuse are not with a manifestation of substance abuse.

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning? 1. "The client claims to feel fat despite being underweight." 2. "The client experiences recurrent episodes of binge eating." 3. "The client exhibits intense fear of gaining weight although underweight." 4. "The client refuses to maintain body weight over a minimal ideal body weight."

2. "The client experiences recurrent episodes of binge eating." Bulimia nervosa is an eating disorder in which the client has an obsessive desire to lose weight. In this condition, bouts of extreme overeating are followed by fasting or self-induced vomiting. A recurrent episode of binge eating is an indicator of bulimia nervosa. A client claims to feel fat despite being underweight may have anorexia nervosa. Other assessment findings of anorexia nervosa include an intense fear of gaining weight despite being underweight and a refusal to maintain a body weight over a minimal ideal body weight.

A client is being evaluated based on client reports of an impairment of a portion of the peripheral vision. After testing is completed, a diagnosis of retinal detachment is made, and a cryosurgical procedure is scheduled. As part of the preoperative teaching, the nurse provides information about what the client can expect and includes which information? 1. An explanation that the surgery will be brief 2. A description of the surgical suite environment 3. The procedure and risks of the repair of the retina 4. The importance of postoperative coughing and deep-breathing exercises

2. A description of the surgical suite environment Because vision will be limited somewhat after surgery, it is important to familiarize the client with vital aspects of the environment, which provides for physical and emotional safety. Surgery usually takes approximately two hours, followed by a stay in the postanesthesia care unit. The healthcare provider should discuss the procedure and risks; informed consent is the primary healthcare provider's responsibility not the nurse's. Coughing or other activity that increases intraocular pressure should be avoided.

A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? Select all that apply. 1. Limiting contact with the abuser 2. Determining a safe place to go in an emergency 3. Memorizing the domestic violence hotline number 4. Obtaining a bank loan to finance leaving the abuser 5. Arranging for a family member to assist her in leaving

2. Determining a safe place to go in an emergency 3. Memorizing the domestic violence hotline number It is important that the client have a safe place to go and a plan for getting there. The client needs to know the hotline number if there is an emergency. It is best to memorize the number because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.

The school nurse is working with a child with a hearing deficit. The child arrives at school today without hearing aids. When the nurse talks with the child about the reasons for not wearing the aids, the nurse will need to ensure that the child understands what is being said. What actions by the nurse will promote effective communication? Select all that apply. 1. Speaking slower, louder than normal, and excessively fast 2. Facing the child directly when talking to the child 3. Avoiding chewing gum while communicating with the child 4. Avoiding using hand expressions that could interfere with lip reading 5. Moving from side to side while talking to the child to keep the child looking at the nurse

2. Facing the child directly when talking to the child 3. Avoiding chewing gum while communicating with the child Many hearing-impaired children have some degree of lip reading skills. This will help the child understand what is being said. Chewing gum alters speech sounds and may alter lip movement, adding to the child's confusion. The nurse should speak slowly but not excessively, because this modifies speech. Speaking louder than normal may distort speech. Hand expressions can add meaning to the spoken words. Standing still while speaking to the child ensures that the speaker's face remains clearly visible.

Which activity is the least therapeutic for a severely depressed client? 1. A simple, short-term activity 2. Having the client select an activity 3. A monotonous, repetitive activity 4. A specific activity to be followed

2. Having the client select an activity It is unreasonable to expect a severely depressed client to select an activity. Severely depressed clients are not motivated to take action or to plan ahead. They are unable to direct their energy toward the environment. If they do select an activity, it may be too difficult for them to complete. Simple, short-term activities are helpful for a severely depressed client whose attention span is limited. Monotonous, repetitive activity is helpful to a severely depressed client, because it requires little thought and provides gratification and satisfaction. A specific activity is helpful for a person who is experiencing depression or who is cognitively impaired.

When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. What does appropriate nursing care for a client with an absent corneal reflex include? 1. Irrigating the eye routinely 2. Instilling artificial tears frequently 3. Checking the corneal reflex every hour 4. Taping the eyelids open during the day

2. Instilling artificial tears frequently Instilling artificial tears frequently lubricates the eye and prevents drying of the cornea. Irrigating the eye is inappropriate; eye irrigations are used to flush foreign matter from the eye. Checking the corneal reflex every hour can lead to corneal abrasion. Taping the eyelid open can cause corneal ulceration or injury.

A client with Meniere disease is advised to eat a sodium-restricted diet to reduce endolymphatic fluid. Which food selection provides evidence that the nurse's teaching was effective? 1. Cake 2. Macaroni 3. Baked clams 4. Grilled cheese

2. Macaroni Macaroni, boiled in unsalted water, has the least sodium of the food choices offered. Cake has a high sodium content, which promotes fluid retention and increases endolymphatic fluid in the cochlea of a client with Meniere disease. Baked clams have a high sodium content, which promotes fluid retention and increases endolymphatic fluid in the cochlea of a client with Meniere disease. Grilled cheese has a high sodium content, which promotes fluid retention and increases endolymphatic fluid in the cochlea of a client with Meniere disease.

A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply. 1. Touching the client to provide reassurance 2. Providing a structured environment for the client 3. Ensuring that the client's nutritional needs are met 4. Engaging the client in conversation about current affairs 5. Designing activities that require the client to maintain contact with reality

2. Providing a structured environment for the client 3. Ensuring that the client's nutritional needs are met Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with a bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorders are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis? 1. Nodules on the pinna 2. Redness of the eardrum 3. Lesions in the external canal 4. Excessive soft cerumen in the external canal

2. Redness of the eardrum Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity but not the manifestation of otitis media. Excessive soft cerumen in the external canal impacts the hearing acuity but not the manifestation of otitis media.

The parents of an adolescent child are worried about their daughter's use of laxatives. Which other behavior in the child does the nurse associate with bulimia nervosa? 1. The child is underweight for her age. 2. The child indulges in binge eating. 3. The child is obsessed with being thin. 4. The child prefers to starve to lose weight.

2. The child indulges in binge eating. Bulimia nervosa is an eating disorder characterized by binge eating and the use of laxatives and self-induced vomiting to prevent weight gain. Anorexia nervosa is a clinical syndrome with both physical and psychosocial components. Clients with anorexia nervosa refuse to maintain body weight at the minimal normal weight for their age and height. An individual with anorexia nervosa has an intense fear of gaining weight. This individual often starves to lose weight.

A nurse notes that an infant with a diagnosis of failure to thrive who has been receiving tube feedings for 3 days has very dry skin and mucous membranes. The nurse verifies that all feedings have been retained, but the daily urine output is consistently 250 mL, and the infant has lost weight. What does the nurse conclude? 1. This is an expected finding in an infant with failure to thrive. 2. The infant is dehydrated, and the fluid intake needs to be increased. 3. This finding is a reflection of the infant's inability to absorb nutrients. 4. The infant is undernourished, and a higher caloric intake will be required.

2. The infant is dehydrated, and the fluid intake needs to be increased. These are classic signs of dehydration; the healthcare provider should be notified because a prescription to increase fluids is needed. It is not common for the condition of an infant with failure to thrive to continue to deteriorate once therapy has been implemented. Although the infant may have a gastrointestinal problem, the classic signs of dehydration must be addressed before this conclusion is reached. These signs indicate dehydration, not undernutrition.

While assessing the eyes of a client, a healthcare provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding might be noted to support a diagnosis of glaucoma? 1. Blurred central vision 2. Increased opacity of the lens 3. Elevated intraocular pressure 4. Changes in retinal blood vessels

3. Elevated intraocular pressure In glaucoma, there is an obstruction of the outflow of aqueous humor due to an intraocular structural damage, which may result from elevated intraocular pressure. Blurred central vision is seen in macular degeneration. Increased opacity of the lens may be seen in cataracts. Retinopathy may result from the changes in retinal blood vessels.

While working in a neuromuscular clinic the nurse monitors infants for symptoms of cerebral palsy. Which statements by infants' mothers indicate the need for further evaluation for cerebral palsy? Select all that apply. 1. "My baby doesn't make eye contact." 2. "My baby seems to have a voracious appetite." 3. "My baby was able to turn from front to back by 2 months of age." 4. "I've noticed that this baby clings to me more than other children of the same age." 5. "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone."

3. "My baby was able to turn from front to back by 2 months of age." 5. "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone." An infant that turns from front to back at an early age will often be found to have spastic cerebral palsy; it is the spasticity that causes an unintentional turn from front to back. Cerebral palsy is a neurologic problem and is commonly recognized when the child fails to meet developmental norms. Failure to make eye contact is often associated with eye issues or autism. Neither anorexia nor a voracious appetite are associated with cerebral palsy. Personality traits are not related to a diagnosis of cerebral palsy.

A client with glaucoma asks a nurse about future treatment and precautions. Which information should the nurse's explanation include? 1. Avoidance of cholinergics 2. Surgical replacement of lens 3. Continuation of therapy for life 4. Prevention of high blood pressure

3. Continuation of therapy for life Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. Cholinergics are used in the treatment of glaucoma; anticholinergics are contraindicated. The surgical replacement of lens is the treatment for cataracts. There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected.

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? 1. Inept 2. Eccentric 3. Impulsive 4. Dependent

3. Impulsive Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Inept behavior, by itself, is not typical of clients with any specific personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is more typical of the client with a dependent personality disorder.

A nurse considers the cultural factors that may influence the development of eating disorders. Where does the nurse recall that eating disorders are more frequently found? 1. Affluent families 2. European countries 3. Industrialized societies 4. Men rather than women

3. Industrialized societies Eating disorders are prevalent in industrialized societies that have an abundance of food; affected individuals likely equate food with pleasure, comfort, and love and may have been nurtured, punished, or rewarded with food. Eating disorders occur in all socioeconomic groups. The incidence and prevalence of eating disorders around the world are similar in European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries with plentiful food supplies. Studies indicate that 95% to 99% of persons with eating disorders are women, not men.

The registered nurse teaches the student nurse regarding the priority of care provided to clients with eye injuries due to chemical exposure. Which activity performed by the student nurse indicates effective learning? 1. Assessing visual acuity 2. Administering analgesics 3. Performing ocular irrigation 4. Covering the eyes with sterile patches

3. Performing ocular irrigation Ocular irrigation with saline solution should be performed immediately in the client with eye injuries due to chemical exposure. Visual acuity tests can be performed after the client's condition is stabilized. Analgesics should be administered after assessing the client's medical records. The client's eyes should be covered with sterile patches after performing ocular irrigation.

A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? Select all that apply. 1. Lack of appetite 2. Depressed mood 3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others

3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others Perseveration (repetition of a behavior pattern) is commonly demonstrated by children with autism; this behavior provides comfort. Self-stimulation through injurious behavior is associated with autism. Children with autism have difficulty communicating or do not communicate at all with others. There may be unusual eating habits and food preferences, but lack of appetite is not associated with autism. Mood disorders are usually not associated with autism.

A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action? 1. Setting limits on manipulative behavior 2. Encouraging participation in group therapy 3. Respecting the client's need for social isolation 4. Recognizing that seductive behavior is expected

3. Respecting the client's need for social isolation These clients are withdrawn, aloof, and socially distant; allowing distance and providing support may foster the eventual development of a therapeutic alliance. Manipulative behavior is typical of clients with the diagnosis of antisocial personality disorder or borderline personality disorder. Group therapy will increase this client's anxiety; cognitive or behavioral therapy is more appropriate. Seductive behavior is associated with clients with the diagnosis of histrionic personality disorder.

While walking to the examination room with the nurse, a toddler with autism suddenly runs to the wall and starts banging the head on it. What should the nurse's initial action be? 1. Allowing the toddler to act out feelings 2. Asking the toddler to stop this behavior 3. Restraining the toddler to prevent head injury 4. Telling the toddler that the behavior is unacceptable

3. Restraining the toddler to prevent head injury The child with autism needs protection from self-injury. Permitting the child to act out is possible only if the acting out does not place the child in jeopardy. The child with autism has difficulty following directions, especially when out of control. The child with autism cannot separate self from behavior; a punitive approach will decrease the child's self-esteem.

Which assessment should the nurse exclude when dealing with a client with receptive and expressive aphasia? 1. Ask the client to read simple sentences aloud 2. Point to a familiar object and ask the client to name it 3. Test the mental status by asking for feedback from the client 4. Ask the client to respond to simple verbal commands such as "Stand up"

3. Test the mental status by asking for feedback from the client Receptive and expressive aphasia are the two types of aphasia. A client with receptive is unable to understand written or verbal speech. A client with expressive aphasia understands written and verbal speech but cannot write or speak appropriately. A client with aphasia may not have the mental ability to give feedback; asking for feedback is ineffective. Asking the client to read simple sentences aloud is an effective way of dealing with this client. Pointing to a familiar object and asking the client to name it is also effective. A client with aphasia can understand simple verbal commands.

A client with newly diagnosed rapid-cycling bipolar disorder will be meeting with the nurse for an educational session about the pharmacological approach that is planned. Which classification of medication does the nurse expect to discuss? 1. Antianxiety medication 2. Antiparkinson medication 3. Antidepressant medication 4. Anticonvulsant medication

4. Anticonvulsant medication Anticonvulsant medications are therapeutic for clients with rapid-cycling bipolar disorder. Antianxiety medications are not primarily used for rapid-cycling bipolar disorder. Antianxiety medications may be helpful for clients with treatment-resistant mania. Antiparkinson medications are not used for rapid-cycling bipolar disorder. An antidepressant medication is not used unless the client also is taking an antipsychotic medication.

The nurse finds that a child has inattention, hyperactivity, and impulsivity upon assessment. Which medication would be beneficial for the child? 1. Modafinil 2. Doxapram 3. Armodafinil 4. Atomoxetine

4. Atomoxetine Inattention, hyperactivity, and impulsivity in a child may indicate that the child has attention deficit hyperactivity disorder. Atomoxetine is a nonstimulant second-line drug used to treat attention deficit hyperactivity disorder (ADHD). Modafinil is a nonamphetamine stimulant used to treat shift-work sleep disorder (SWSD). Doxapram and armodafinil are nonamphetamine stimulants used to treat shift-work sleep disorder (SWSD).

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply. 1. Passivity 2. Fatigue 3. Anhedonia 4. Grandiosity 5. Talkativeness 6. Distractibility

4. Grandiosity 5. Talkativeness 6. Distractibility Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client's rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Fatigue is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? 1. Constant blurring 2. Abrupt attacks of acute pain 3. Sudden, complete loss of vision 4. Impairment of peripheral vision

4. Impairment of peripheral vision Open-angle glaucoma[1][2] has an insidious onset, with increased intraocular pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes. Constant blurring may occur with untreated acute angle-closure glaucoma. Pain occurs in acute angle-closure, not open-angle, glaucoma. Occlusions of the central retinal artery or retinal detachment will cause a sudden loss of vision.

A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery? 1. Radiation 2. Burr holes 3. Dermabrasion 4. Laser technique

4. Laser technique A laser beam causes a thermal inflammatory response, which results in a chorioretinal scar that holds the retina in place. Radiation is not used, because it destroys retinal tissue. Burr holes are used in brain, not retinal, surgery. Dermabrasion is used for acne vulgaris and other disfiguring skin conditions, not retinal surgery.

An adolescent who works out 6 hours a day reports not eating well, weight loss, and an absence of menses for the past few months. Which nursing intervention is most appropriate? 1. Ask the adolescent to stop exercising for a few days. 2. Talk to the client to find out any reasons for stress. 3. Perform a β-human chorionic gonadotropin pregnancy test. 4. Modify the adolescent's diet to incorporate more nutrients.

4. Modify the adolescent's diet to incorporate more nutrients. If an athletic adolescent experiences symptoms of eating disorders, weight loss, and an absence of menses indicating female athlete triad, then her diet should be modified incorporate more nutrients. Asking the adolescent to stop exercising for a few days would not solve the problem. Stress does not cause amenorrhea. Being an athlete and having eating disorders rules out the chances for becoming pregnant.

The nurse assesses a 65-year-old client's electronic medical records and notices a history of increased lens density. Which nursing actions will be most appropriate for this client? Select all that apply. 1. Performing keratoplasty 2. Performing phacoemulsification 3. Monitoring for pain and eye redness 4. Monitoring the client's blood glucose levels 5. Assessing if the client is under antiplatelet medication

4. Monitoring the client's blood glucose levels 5. Assessing if the client is under antiplatelet medication A client with cataracts has increased lens density due to drying and compression of older lens fibers. Clients with disease conditions such as diabetes mellitus may develop cataracts. Therefore the client's blood glucose levels should be assessed to determine the severity of the disease. Surgery is the only "cure" for cataracts. Before performing surgery, the client should be assessed for any conditions that may affect blood clotting, such as use of aspirin and clopidogrel. Phacoemulsification is the surgical procedure performed in a client with cataracts in which the lens is extracted. Keratoplasty is performed in a client with improper corneal shape. Pain and redness is not observed in age-related cataract. Both phacoemulsification and keratoplasty are surgical procedures and not nursing actions.

During a well-child visit the parents tell a nurse, "Our 3-year-old doesn't listen to us when we speak and ignores us!" An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss? 1. A severe hearing deficit may develop. 2. It will not interfere with progress in school. 3. An immediate follow-up visit is not necessary. 4. Speech therapy in addition to hearing aids may be required.

4. Speech therapy in addition to hearing aids may be required. A mild degree of hearing loss causes the child to miss approximately 25% to 40% of conversations; it may result in speech deficits and interfere with the child's educational progress if it is not corrected. Hearing aids usually help improve function. There is no evidence that this child's hearing loss is progressive. The significance of the hearing loss requires further analysis and intervention.

A nurse in the pediatric clinic should be most observant for signs of cerebral palsy in a 6-month-old infant in which instance? 1. Has a 40-year-old mother 2. Was born exhibiting the Moro reflex 3. Was delivered by an elective cesarean birth 4. Was born during the 32nd week of gestation

4. Was born during the 32nd week of gestation Studies indicate that a large percentage of children with cerebral palsy had preterm births and weighed less than 3 lb 5 oz (1500 g) at birth. Studies do not indicate a greater incidence of cerebral palsy in children born to older women. There is no greater incidence of cerebral palsy in children born in cesarean births that are not performed because of fetal distress. The Moro reflex is expected at birth.