pearson fundamentals exam 2
A healthcare provider refuses to prescribe opioids to a patient. The patient returns to the office and fatally shoots the healthcare provider. This example of a fatality falls into which category?
Workplace violence
The nurse is providing discharge teaching for a patient who has absent tactile sensation below the umbilical area. Which patient statement indicates that further teaching is needed?
"I will avoid taking baths."
The nurse is conducting a program on summer safety for families of a residential community. Which participant statement indicates that the teaching has been effective?
"Children should learn how to swim."
The nurse is providing teaching about communication for the family of a patient who is hearing impaired. Which statement by the family member indicates further teaching is needed?
"I will speak in short sentences."
Which action should the nurse identify as a component of standard precautions?
Washing hands and donning gloves before administering an injection
The nurse observes sudden changes in a client during assessment, including weakened vital signs, diaphoresis, and labored breathing. Which type of acute changes is the nurse observing?
physical
The nurse is performing a hearing assessment using the Weber test for a patient experiencing hearing loss. The patient asks the nurse, "What is the reason for this test?" Which information should the nurse include in the response?
"To assist in determining the type of hearing loss you may have"
A patient with a newly delivered baby asks the nurse, "How do I know if my baby can hear?" Which information should the nurse provide?
"We will perform a hearing screening prior to discharge from the hospital."
The nurse is caring for several patients. Which patient should the nurse identify as having special safety needs?
27-year-old who has autism and is recovering from a broken arm
The nurse finds a 14-year-old client watching MTV at full blast. Which safety issue should the nurse address with the client?
Adolescents need to be reminded that loud music can lead to hearing loss.
The nurse is reviewing the chart of a patient that has smoked half a pack of cigarettes a day for the past 25 years. Which subjective assessment finding should the nurse anticipate in this patient?
Altered sense of taste
The nurse is caring for an older adult who has experienced a loss of vision. Which will the nurse implement into the plan of care?
Announcing presence when entering the room
The nurse smells fumes when one of the housekeeping staff spills a bottle of concentrated cleaner onto the floor. Which action should the nurse perform?
Find out how to safely dispose of the liquid
While removing a trash bag from the room of a patient in protective isolation, the nurse sustains a needlestick. Which educational topic is a priority for nurses on the unit to discuss during the next staff meeting?
Appropriate disposal of used sharps.
The nurse is preparing to assess kinesthesia in a patient. Which technique should the nurse use?
Ask the patient to move their finger up or down and describe the movement.
An older patient tells the nurse, "I take the water pill and a red one every day, and after dinner I take a vitamin." Which is a nursing intervention to safely reconcile the patient's home medications with those to be given in the hospital?
Asking a family member to bring in a list of the patient's medications with dosages
The nurse is caring for a patient who is scheduled for evaluation and a prescription for a hearing aid. Which collaborative referral should the nurse anticipate will be prescribed for the patient?
Audiologist
The nurse is caring for an older adult experiencing a loss of hearing. Which prescribed procedure should the nurse anticipate being used to evaluate the hearing loss?
Audiometry
The nurse is caring for an older adult patient who is experiencing visual loss resulting from cataracts. The nurse should understand that which factor contributes to the development of cataracts?
Breakdown of the proteins in the lens
The nurse is preparing to assess cranial nerve III, the oculomotor nerve. Which assessment should the nurse use?
Cardinal fields
The nurse is caring for an older adult patient who is experiencing visual loss that has manifested as opacification of the lens of the eye. Based on this manifestation, the nurse should understand that this patient has which condition?
Cataract
While performing patient care, the nurse notes an area of skin breakdown and excoriation along the area where the indwelling urinary catheter is affixed to the patient's inner thigh. Which is the priority nursing intervention?
Change the catheter using one without latex
The nurse who is physically, mentally, and emotionally depleted states, "I just want to retire. I don't care anymore." Which condition is the nurse experiencing?
Compassion fatigue
The nurse is caring for an 18-month-old child diagnosed with amblyopia. The mother asks the nurse what will be done to straighten the child's eye. Which information should the nurse include in the response to the parent?
Covering the healthy eye to encourage the affected eye to process images and strengthen the eye
The nurse is preparing to assess a patient reporting loss of smell. Which cranial nerve should the nurse suspect is a factor in the patient's symptoms?
Cranial nerve I (olifactory nerve)
The nurse is teaching new mothers about safe sleeping for newborns. Which recommendation should the nurse include?
Dress newborns in warm clothing and place them on their backs while in a crib.
The nurse is caring for an adolescent who has aggressive behavior and an adolescent recovering from an attempted suicide. The nurse should recognize that the patients most likely share which root cause for their behavior?
Emotional turmoil
The nurse should identify which intervention as one that will reduce the risk of falls in the healthcare environment?
Encouraging the use of the call button
The nurse is evaluating the success of actions taken to reduce the incidence of staff illnesses in the work area. Which information best suggests that the actions have been successful?
Every staff nurse has received the annual flu vaccination.
Which independent nursing intervention would support the goal of preventing sensory overload?
Explain environmental sounds
The nurse is caring for a patient who has a sudden loss of feeling and paralysis in a limb. Which is the most accurate description of the type of change the patient is experiencing?
Functional
The nurse is caring for an older adult patient who walks with a cane and needs help with household chores. Which type of decline represents the patient's current status?
Functional
During a recent community survey on local swimming pools, the public health nurse becomes concerned about the risk of water-related injuries for community members. Which survey result has led to this concern?
Home swimming pools lacking four-sided barriers
The nurse is assessing a child with a history of otitis media. The nurse observes a reddened, inflamed tympanic membrane in the right ear. Based on the child's history of recurrent otitis media, which procedure should the nurse expect to be recommended?
Insertion of ear tubes
The nurse is reviewing the chart of a patient diagnosed with nystagmus. Based on the patient's diagnosis, which assessment finding should the nurse anticipate?
Involuntary eye movements
The nurse is providing care to a patient experiencing hearing loss due to impacted cerumen. The nurse should provide teaching for which procedure?
Irrigation with warm water and ear wax softener
The home health nurse brings supplies into the patient's room and lays them down on the carpet before beginning to assess the patient. Which safety risk does this pose?
It may result in infection transmission
The family member of a patient with a visual field deficit asks the nurse what they should do to prevent injury. Which suggestion by the nurse is most appropriate?
Keep the floor free of obstacles.
While conducting a home visit, the nurse observes a new mother heat the water to the proper temperature, place the infant in a sink for a morning bath, and then walk away to collect towels and soap. Which topic should the nurse use to guide teaching for this mother?
Knowledge deficit
The nurse has observed that a patient has abnormal results for a kinesthesia test. Which causative factor is most likely associated with the abnormal finding
Lesion on the posterior column of the spinal cord
The nurse is caring for a client with Down syndrome who likes to say "hi" to everyone and strike up conversations. Which important safety information should the nurse teach the caregivers?
Monitor the client's interactions to make sure the client is engaging with safe people.
The nurse is concluding a visual assessment for a patient and determines the patient is unable to read the 20/20 line on the Snellen chart. Which is the appropriate interpretation of this clinical finding?
Myopia
The nurse caring for a patient who has a chronic staph infection on their legs performs a home environmental assessment. Which finding may be the cause of the infection?
Old upholstery with years of accumulated dirt
The nurse asks a family member of an older adult patient to bring in the patient's medicines that they take at home. What is the nurse's primary purpose for this request?
Performing medication reconciliation
The nurse is providing discharge teaching for the family caring for a patient who is newly diagnosed with impaired vision. Which information should the nurse include?
Place shades on windows.
A patient with a hearing impairment has been referred to an audiologist. Which type of intervention should the nurse expect will be provided?
Prescription for hearing aid
The nurse is caring for clients who have dementia on a locked unit. Which is an important safety issue for the nurse to remember during daily work? (Select all that apply.)
Residents need regular exercise to maintain muscle strength and joint flexibility. Medications should be locked away to prevent impaired clients from accidental ingestion and errors. Cognitively impaired adults are at risk for falls.
The nurse is caring for an older adult client that requires a visual aid for reading. Based on the client's need, which visual change has the client experienced?
presbyopia
The nurse is teaching a pregnant patient about measures to prevent injury to herself as well as the fetus. Which recommendation should the nurse include?
Smoking cessation
The nurse is admitting a patient with visual impairment to the hospital. Which communication technique should the nurse utilize?
Speak in a pleasant tone of voice.
The nurse is performing an eye exam on a newborn and observes strabismus. Which statement describes the nurse's interpretation of the assessment finding
Strabismus in a newborn is a normal finding.
Which high school students should the nurse identify as having high risk for injury?
Students with volatile tempers and poor problem-solving skills
Which symptom in a patient should the nurse identify as an acute functional change?
Sudden numbness and weakness in a limb
The nurse is teaching a class about workplace violence. Which example of violence should the nurse include? (Select all that apply.)
The client who throws his tray at staff, the family member who threatens a staff member's life, and staff members bullying a fellow employee are all examples of workplace violence.
The nurse observes an energetic coworker take narcotics from the dispensing system. The nurse also observes the coworker fail to administer medication to patients in pain and be short-tempered. Which should the nurse suspect about the coworker?
The coworker is impaired and unable to work safely.
The hospital uses a common disinfectant wipe that is rumored to cause cancer. Which appropriate step should the hospital take to ensure worker and community safety? (Select all that apply.)
The hospital should investigate the safety of this product and look for safer disinfectants if needed. In the meantime, employees should be instructed to use gloves to minimize risk. The hospital should also join Go Green or another environmental initiative to learn about safe disposal of hazardous medical waste.
The nurse is making a home visit and is wearing a scrub top, scrub pants, and a windbreaker when the outside temperature is 45F. Which safety concern should the nurse consider regarding clothing choice?
The nurse should dress in layers in case the home is poorly heated or without heat.
During physical therapy, the nurse notices that an older adult client keeps tripping and bumping into things while walking. Which important safety measure should the nurse implement? (Select all that apply.)
The nurse should proactively work on obtaining a vision exam and new glasses prescription. In the meantime, for safety, the nurse needs to remind the client to use a walker or cane to maintain balance. Remind the therapist to cue the client to unexpected changes in the walking surface. Encourage the client to use a gait belt to keep the client safe from sudden falls.
The nurse is assessing a patient with a history of myopia. Which deficit should the nurse expect to find in this patient?
The patient is unable to read the 20/20 line on the Snellen chart.
Which rationale should the nurse understand is a patient-centered advantage of chemical restraints versus seclusion?
The patient treated with a chemical restraint maintains freedom of movement
A parent asks the nurse why toddlers are at high risk for accidental death and injuries. Which reason should the nurse include in the response?
Their small size and developing bones make them vulnerable to injuries
The nurse recommends removing scatter rugs, installing easy grip faucets, providing adequate lighting, and installing raised toilet seats in the patient's home. Which is the rationale for these environmental safety improvements?
These services make the patient feel safe and secure.
The nurse is caring for a patient with newly diagnosed open-angle glaucoma. The patient is prescribed a medication as part of the treatment plan. Which describes the primary purpose of the medication
To control intraocular pressure
The nurse instructs parents not to allow a 6-year-old patient to race their younger sibling down the hospital halls. Which is the primary reason behind this action?
To prevent injury to the patient and others
The nurse is teaching a class about drowning risks. Which age group should the nurse explain as having the highest risk of drowning in a pool?
Toddlers
Which measure should the nurse suggest for toddler-proofing a home? (Select all that apply.)
Toys should be age-appropriate so that toddlers cannot swallow them and block an airway or injure themselves on sharp corners. Food should be cut properly to prevent choking. Cleaning supplies and medications need to be locked away and out of reach to prevent poisoning.
The nurse is caring for an older adult patient with a hearing deficit. Which initial intervention should the nurse include in the plan of care when communicating with the patient?
Use longer phrases.
Which action by the nurse risks a needlestick injury? (Select all that apply.)
Uses improper hand technique in administering shots Recaps a dirty needle Places a needle in an unapproved disposal device Attempts to put a needle into a full sharps container
The nurse assessing the lacrimal glands of a newborn observes excessive tearing in the right eye. Which most accurately describes the etiology of the assessment finding?
blockage of the nasolacrimal duct.
While completing a health history, the nurse becomes concerned that a pregnant client is at risk for having a miscarriage. Which information in the client's history is causing this concern? (Select all that apply.)
caffeine intake, illegal drug usage, tobacco usage, and older maternal age.
The nurse is caring for a client who has experienced a permanent hearing loss. Which referral is most beneficial to assist the client in adjusting to the sensory deficit?
class for American sign language
The nurse is providing visual screenings for school-age children. The nurse understands that which visual problem is most commonly diagnosed in school-age children?
convergence
The nurse is testing a client's six cardinal fields of vision. Which cranial nerves is the nurse assessing? (Select all that apply.)
cranial nerves IV, VI, and III, which are involved in oculomotor movement
The nurse is reviewing the prescription for a client requiring a surgical procedure to remove cataracts. The nurse understands that which collaborative team member will most likely perform the client's surgery?
ophthalmologist
The nurse is reviewing the chart of an older adult client. Which sensory changes does the nurse anticipate have occurred? (Select all that apply.)
decreased sense of hearing, a decreased sense of taste, and an impaired sense of smell.
The nurse is caring for a client with visual impairment. The nurse understands that which comorbidity is associated with visual deficits? (Select all that apply.)
diabetes, hypertension, and stroke.
Which intervention should the nurse implement as a standard safety measure for adult clients? (Select all that apply.)
encouraging the use of the call button, maintaining fluid intake, preventing infection through the use of soap or hand sanitizer, and letting the nurse know if pain increases or condition changes.
The nurse is reviewing the physiology of sensory perception. Which sensory perceptions are associated with internal stimuli? (Select all that apply.)
gustatory (ability to taste), visceral (stimuli from a large organ), and stereognosis (the ability to perceive and understand objects through touch).
The nurse is preparing to examine the ears of a 2-year-old child. Which intervention should the nurse implement prior to the assessment?
have the parent help hold the young child's head against their chest to prevent movement.
A nurse is providing teaching for a client diagnosed with an olfactory deficit. Which interventions specifically related to an olfactory deficit will the nurse include in the teaching? (Select all that apply.)
heck the expiration dates on the food and review the safety of cleaning supplies.
A client's intravenous line with a vesicant medication becomes disconnected, and the fluid is running down the hospital bed onto the floor. Which action should the nurse take?
identify the medication so that a safety data sheet can be accessed to properly address the spill.
The nurse is preparing to assess a client's sensory function. Which neurosensory assessments will the nurse include? (Select all that apply.)
kinesthesia, distinguishing between hot and cold sensation, identification of vibration, and distinguishing between sharp and dull sensations.
The nurse is admitting a client for the treatment of closed-angle glaucoma. Which procedure should the nurse anticipate will be performed?
laser iridotomy
The nurse is reviewing the chart of a client diagnosed with strabismus. Which most accurately describes the nurse's understanding of the diagnosis?
misalignment of the eyes.
The nurse is caring for a 9-year-old client who was injured while riding a bicycle down a steep hill while the client's mother was at work. Which underlying safety issue should the nurse address? (Select all that apply.)
review bicycle safety, peer involvement, latchkey children's emotional needs, and reasons for risky behavior.
The nurse observes a mother, father, and toddler coming in to visit a client. The toddler has a runny nose and is sniffling. Which safety concern should the nurse address before letting the family visit the client?
risk of infection
The nurse is caring for a client at risk for sensory overload. Which nursing interventions will the nurse implement? (Select all that apply.)
shading the windows, scheduling cluster care, explaining environmental sounds, and providing earphones for the client
The nurse is assessing a visually impaired client's home environment for safety. Which finding is most concerning for the nurse?
throw rugs
The nurse is caring for a pregnant client hospitalized with preeclampsia who can only walk with supervision. Which is the most important safety measure the nurse should teach the client to prevent injury?
using the call button
A patient states she is "feeling dizzy and having trouble with balance." The nurse should recognize that the patient is experiencing which alteration in sensory perception?
vertigo
The nurse is caring for an adult client with hyperlipidemia. Which assessment finding is most associated with the client's diagnosis?
xanthelasma
The nurse taught a group of high school students actions to prevent injury. Which student comment indicates an understanding of the teaching? (Select all that apply.)
"I can talk to a teacher if I am faced with peer pressure to use drugs." "I should not get into a car when the driver has been drinking." "I hate it, but I will wear a helmet when riding my bike." "If I feel really down, I need to talk to my parents about it."
The nurse is caring for a visually impaired client who will be utilizing a service dog. Which statement most accurately describes the nurse's understanding of service dogs?
"The service dog can assist with activities of daily living."
The nurse is caring for a client with open-angle glaucoma who is concerned about treatment of the condition. Which statement by the nurse most accurately describes the treatment plan for the client?
"You will be prescribed medication for treatment."