Sensory

The nurse discovers the type 1 diabetic (IDDM) patient drowsy and tremulous, the skin is cool and moist, and the respirations are 32 and shallow. These are signs of: A. hypoglycemic reaction; give 6 oz of orange juice. B. hyperglycemic reaction; give ordered regular insulin. C. hyperglycemic hyperosmolar nonketotic reaction; squeeze glucagon gel in buccal cavity. D. hypoglycemic reaction; give ordered insulin.

A. hypoglycemic reaction; give 6 oz of orange juice.

Which may contribute to otitis media? (Select all that apply.) A. Exposure to cigarette smoke B. Allergies C. Upper respiratory infections D. Swimming E. Trauma F. Prolonged exposure to loud noise

A. Exposure to cigarette smoke B. Allergies C. Upper respiratory infections

Which test will furnish immediate feedback for a newly diagnosed diabetic who is not yet under control? A. Fasting blood sugar (FBS) B. Glycosylated hemoglobin (HgbA1c) C. Oral glucose tolerance test (OGTT) D. Clinitest

A. Fasting blood sugar (FBS)

Which of the following are causes of cataracts? (Select all that apply.) A. Long-term use of corticosteroids B. Hypotension C. Congenital from exposure to maternal rubella D. Diabetes mellitus E. Exposure to sand and dust F. Smoking

A. Long-term use of corticosteroids D. Diabetes mellitus F. Smoking

What is a common mistake that hinders communication when communicating with the hearing impaired? A. Overaccentuating words B. Facing the patient when speaking C. Speaking in conversational tones D. Speaking into the ear with the hearing aid

A. Overaccentuating words

The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate? A. Sjögren syndrome B. Early cataracts C. Macular degeneration D. Retinal detachment

A. Sjögren syndrome

Which is a sign of acute angle closure glaucoma (AACG)? A. Large fixed pupil B. Nystagmus C. Bluish color in sclera D. Drooping eyelid

A. Large fixed pupil

What should the nurse include in the plan of care following a tympanoplasty? A. Elevating head of bed with operative side facing upward B. Enforcing bed rest for 72 hours C. Frequent turning, coughing, and deep breathing D. Continuous irrigation of the ear canal with antibiotic solutions

A. Elevating head of bed with operative side facing upward

The nurse provides discharge teaching for a patient regarding her activity level as she recovers from her modified radical mastectomy. Which statement by her indicates to the nurse that the teaching has been successful? A. "I should sleep on the side opposite my mastectomy." B. "I should keep my right arm supported in a sling when I am up and around until my incision is healed." C. "I can do whatever exercises and activities I want as long as I don't elevate my right hand above my head." D. "I should take aspirin before moving or exercising my arm to prevent pain during the exercises."

A. "I should sleep on the side opposite my mastectomy."

What is the process when the lens of the eye changes its curvature to focus on the retina? A. Accommodation B. Constriction C. Convergence D. Refraction

A. Accommodation

What does a tympanoplasty correct? A. Conductive hearing loss B. Sensorineural hearing loss C. Congenital hearing loss D. Functional hearing loss

A. Conductive hearing loss

The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take? A. Warm the irrigating solution to 98 degrees F. B. position the client with the affected side up after the irrigation C. direct a slow, steady stream of irrigation solution toward the eardrum D. assist the client to turn his or her head so that the irrigated ear is facing upward

A. Warm the irrigating solution to 98 degrees F.

Pilocarpine hydrochloride is prescribed for the client with glaucoma. which medication should the nurse plan to have available in case there is the event of systemic toxicity? A. atropine sulfate B. timolol maleate (timoptic) C. metipranolol (OptiPranolol) D. Carteolol hydrochloride (Ocupress)

A. atropine sulfate

When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact? A. American Red Cross B. American Foundation for the Blind for a list of agencies C. Local hospital social worker D. The public health department

B. American Foundation for the Blind for a list of agencies

A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care? A. Turn, cough, and deep breathe every 3 hours B. Apply a pressure dressing over the right eye socket C. Document dressing assessment every 2 hours D. Turn on the affected side

B. Apply a pressure dressing over the right eye socket

Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts? A. Pain in the eyes B. Difficulty driving at night C. Loss of peripheral vision D. Dry eyes

B. Difficulty driving at night

On the second postoperative day, a patient who has had an abdominal hysterectomy complains of gas and abdominal distention. Which intervention would be most appropriate to stimulate a bowel movement? A. Offering carbonated beverages B. Encouraging ambulation at least four times per day C. Administering a 1000-mL soapsuds enema D. Applying an abdominal binder

B. Encouraging ambulation at least four times per day

What must a patient do following a left vitrectomy? A. Remain flat in bed for 48 hours B. Position self in a face-down position for 4 to 5 days C. Assume a side-lying position with the left side down for 3 days D. Keep head upright and cushioned with pillows for 24 hours

B. Position self in a face-down position for 4 to 5 days

Four hours after a stapedectomy the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response? A. A large percentage of stapedectomies are not successful B. It will take at least 10 days for the graft to heal C. Hearing will not return until edema subsides D. Hearing will improve after irrigation of the ear

C. Hearing will not return until edema subsides

A patient is suspected of having a retinal detachment. What signs/symptoms will provide support to this diagnosis? Select all that apply. A. I have tunnel vision B. I am having a lot of pain in my eye C. I see specks floating around the edges of my vision D. I feel like someone pulled a curtain over my eye

C. I see specks floating around the edges of my vision D. I feel like someone pulled a curtain over my eye

What do the Chvostek sign and the Trousseau sign indicate? A. Low levels of serum calcium B. High levels of blood sugar C. Low levels of serum sodium D. High levels of serum aldosterone

C. Low levels of serum sodium

What does diabetes retinopathy result from? A. Capillaries in retina hemorrhage B. Long-term overdosing of insulin C. Retinal detachment D. Aging

C. Retinal detachment

What is an appropriate nursing diagnosis for a patient who has recently been diagnosed with acromegaly? A. Ineffective coping B. Activity intolerance C. Risk for trauma D. Chronic low self-esteem

C. Risk for trauma

What should a patient who has had a cataract repair avoid? A. The use of eye patches B. The use of sunglasses C. The lifting of heavy objects D. Reading for long periods of time

C. The lifting of heavy objects

Why would the nurse encourage the patient who is recovering from a modified radical mastectomy to exercise the affected arm? A. To reduce pain B. To stimulate appetite C. To reduce lymphedema D. To increase muscle tension

C. To reduce lymphedema

The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK: A. reshapes the central cornea. B. makes partial-thickness radial incisions in the cornea. C. removes some internal layers of the cornea. D. implants intracorneal rings.

C. removes some internal layers of the cornea.

The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at _______ feet. A. 10 B. 20 C. 30 D. 40

D. 40

What does the cataract treatment of phacoemulsification involve? A. "Drying" the cataract with hypertonic saline B. Removing the lens through the anterior capsule C. The insertion of a new lens D. Breaking the cataract with ultrasound

D. Breaking the cataract with ultrasound

One of the housekeepers splashes a chemical in the eyes. What should be the first priority? A. Transport to a physician immediately B. Cover the eyes with a sterile gauze C. Irrigate with H O for 5 minutes D. Irrigate with normal saline solution for 20 minutes

D. Irrigate with normal saline solution for 20 minutes

How should the nurse advise a patient who has severe vertigo from labyrinthitis? A. Lean against a wall and not head forward until vertigo lessens. B. Bend at the waist and take several deep breaths. C. Drink an iced drink slowly. D. Lie immobile and hold the head in one position until the vertigo lessens.

D. Lie immobile and hold the head in one position until the vertigo lessens.

The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient? A. The patient would be considered totally blind. B. This patient probably has some light perception, but no usable vision. C. This patient has some usable vision, which enables function at an acceptable level. D. The nurse would need to determine how this patient's visual impairment affects normal functioning.

D. The nurse would need to determine how this patient's visual impairment affects normal functioning.

How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy? A. The procedure will destroy the retina, which is not getting enough blood supply. B. The procedure will reduce edema in the macula of the eye. C. The procedure will vaporize fatty deposits that appear in the retina. D. The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.

D. The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.

A 20-year-old patient presents in the emergency room with a temperature of 103° F, blood pressure of 92/58, headache, and desquamation of both palms. What should the nurse make sure to ask about during the interview? A. Any recent traveling outside the country B. Immunization against influenza C. Method of birth control D. Use of tampons

D. Use of tampons

The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? A. decrease the amount of salt in the diet B. decrease fluid intake to control the intraocular pressure C. avoid reading the newspaper and watching television D. eye medications will need to be administered for the rest of your life

D. eye medications will need to be administered for the rest of your life

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? A. irrigation of the ear B. installation of antibiotic eardrops C. instillation of corticosteroid ointment D. instillation of mineral oil or diluted alcohol

D. instillation of mineral oil or diluted alcohol

How should the nurse administer insulin to prevent lipohypertrophy? A. At room temperature B. At body temperature C. Straight from the refrigerator D. After rolling bottle between hands to warm

A. At room temperature

A 25-year-old woman comes to the clinic with a yellowish-green malodorous vaginal discharge. She says it makes her itch and makes it hard to urinate. After a microscopic examination that confirms trichomoniasis, the patient is placed on metronidazole (Flagyl) for 7 days. How should the nurse advise the patient? A. Avoid alcohol while on Flagyl B. Be aware that her urine may turn blue and will stain clothing C. Wear snug underwear during treatment D. Be aware that she need not notify her sexual partners as trichomoniasis is not contagious

A. Avoid alcohol while on Flagyl

When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition? A. Detached retina B. Macular degeneration C. Early sign of cataract D. Diabetic retinopathy

A. Detached retina

the nurse is preparing to administer ear drops to an adult client. the nurse administers the eardrops by which technique? A. pulling the pinna up and back B. pulling the earlobe down and back C. tilting the client's head forward and down D. instructing the client to stand and lean to one side

A. pulling the pinna up and back

The nurse is assessing the feet of a client with long term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? A. The client has crumbling toenails B. The client has a necrotic big toe C. The client has athlete's foot D. The client has thickened toenails

B. The client has a necrotic big toe

What is the first indication of macular degeneration? A. The loss of peripheral vision B. The loss of central vision C. The loss of color discrimination D. Eye fatigue

B. The loss of central vision

The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone: A. equally in both ears. B. as a shrill noise. C. louder in his affected ear. D. very faintly.

C. louder in his affected ear.

The nurse teaching a patient with type 1 diabetes mellitus (IDDM) about early signs of insulin reaction would include information about: A. abdominal pain and nausea. B. dyspnea and pallor. C. flushing of the skin and headache. D. hunger and a trembling sensation.

D. hunger and a trembling sensation.

A patient tells the nurse he has dizziness. he states that the health care provider used another term. What term did the healthcare provider most likely use? A. tinnitus B. labyrinthitis C. sensorineural D. vertigo

D. vertigo

A 78 year old patient comes to the clinic complaining of progressive loss vision in the center of the visual field. The nurse is aware that the patient is most likely experiencing symptoms of which disorder? A. macular degeneration B. primary open angle glaucoma C. color blindness D. retinal degeneration

A. macular degeneration

The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take? A. warm the irrigating solution to 98 degrees B. position the client with the affected side up after the irrigation C. direct a slow, steady stream of irrigation solution toward the eardrum D. assist the client to turn his head or her head so that the ear to be irrigated is facing upward

A. warm the irrigating solution to 98 degrees

A patient has just had cataract surgery. What information should the nurse include in the discharge instructions (select all that apply) A. wear an eye shield at night on the operative eye B. avoid bending, stooping, coughing or lifting C. instill prescribed eye drops into the conjunctival sac D. take an analgesic every four hours

A. wear an eye shield at night on the operative eye B. avoid bending, stooping, coughing or lifting C. instill prescribed eye drops into the conjunctival sac

Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for side effects of this medication? A. monitoring temperature B. monitoring blood pressure C. checking peripheral pulses D. checking the blood glucose level

B. monitoring blood pressure

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? A. Betaxalol (betoptic) B. pilocarpine (ocusert pil 20) C. atropine sulfate (isoto atropine) D. pilocarpine hydrochloride (Isopto carpine)

C. atropine sulfate (isoto atropine)

The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to: A. damaged tympanic membrane. B. protective buildup of cerumen. C. damage of the fine hair cells in the organ of Corti. D. rupture of the oval window.

C. damage of the fine hair cells in the organ of Corti.

A patient is diagnosed with an inner ear problem. What symptom should the nurse monitor the patient closely for? A. echoing B. intense pain C. vertigo D. loss of hearing

C. vertigo

A client is diagnosed with glaucoma. which data gathered by the nurse indicate a risk factor associated with glaucoma? A. Cardiovascular disease B. a history of migraine headaches C. frequent urinary tract infections D. frequent upper respiratory infections

A. Cardiovascular disease

Why is otitis media found more frequently in children 6 to 36 months? A. Eustachian tubes in children are shorter and straighter. B. Infection descends via the eustachian tube to the throat. C. Children's eustachian tubes are more vertical and longer. D. Otitis media is seen equally in both children and adults.

A. Eustachian tubes in children are shorter and straighter.

What is a long-term complication of diabetes mellitus? A. Diverticulitis B. Renal failure C. Hypothyroidism D. Hyperglycemia

B. Renal failure

The nurse will assess for _____________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain. A. mumps B. external otitis C. otitis media D. labyrinthitis

B. external otitis

Which assessment finding would indicate a need for possible glaucoma testing? A. presence of floaters B. halos around lights C. progressive loss of peripheral vision D. pruritus and erythema of the conjunctiva

B. halos around lights C. progressive loss of peripheral vision

A patient is scheduled for a stapedectomy. what postoperative instructions should the nurse include in patient teaching? select all that apply. A. change cotton in external ear canal hourly B. gently blow both nares simultaneously C. teach the patient to open the mouth when sneezing or coughing D. limit exercise or active sports for three weeks E. Avoid exposure to people with upper respiratory tract infections

C. teach the patient to open the mouth when sneezing or coughing D. limit exercise or active sports for three weeks E. Avoid exposure to people with upper respiratory tract infections

While cleaning the garage a patient splashed a chemical in his eyes. what is the initial action following the chemical burn? A. transport to an emergency facility immediately B. cover the eyes with sterile gauze C. lubricate the eye with petroleum based jelly D. irrigate the eye with water for 20 minutes

D. irrigate the eye with water for 20 minutes

A patient is asked to sign a surgical consent for treatment of otosclerosis. Which statement indicates correct understanding of the procedure? A. it involves surgical repair of the external ear B. it means cutting the nerve in my ear C. it cleans the ear canal of wax D. it will help me hear sounds again

D. it will help me hear sounds again