Week 8 (Ch 7, 8, 19, 20)
A client diagnosed with posttraumatic stress disorder (PTSD) tells the nurse about having "flashbacks" during waking hours or nightmares in which the past traumatic event is relived, often in vivid and frightening detail. What term for this experience will the nurse document in the client's record?
Intrusion
A client with a history of posttraumatic stress syndrome reports frequently reliving the traumatic event. The nurse documents that the client is experiencing:
Intrusion
The nurse is admitting a client documented to have papilledema. The nurse recognizes that papilledema is most commonly caused by which condition?
Intracranial pressure
Impaired function of which eye structure is responsible for blurred vision and loss of fine tuning of focus?
Lens
A nurse is caring for a client with hypoparathyroidism. Which imbalance is a major concern for the client?
Hypocalcemia
When caring for the client with hyperkalemia, the nurse recognizes the body should respond in which of these ways?
secrete potassium in the distal tubules for excretion
The fight-or-flight response is a manifestation of the stress reaction caused by which part of the nervous system?
Sympathetic
The pathophysiology student is studying the general adaptation syndrome (GAS). Which statement by the student demonstrates understanding?
"Epinephrine is released in the alarm stage."
The nurse is performing a health history for a 72-year-old client. When reviewing the client's medications, the client states, "I take a baby aspirin every day, but I'm worried. I heard that aspirin can cause hearing problems!" What is an appropriate response by the nurse?
"A baby aspirin is a low dose that is considered to be safe."
An older adult client has been diagnosed with macular degeneration. Which statement by the client best demonstrates an accurate understanding of the new diagnosis?
"I suppose that this may be one of the things that happens when you get older."
The nurse is teaching a teenaged client strategies to avoid recurrent ear infections. The nurse understands that further teaching is required when the client states:
"I will dry the inside of my ears thoroughly with cotton-tipped applicators after swimming."
The nurse has just received the laboratory results of a client's calcium level. The nurse identifies a normal calcium level as:
8.5 to 10.5 mg/dl (2.25 mmol/l to 2.6 mmol/l)
The nurse is caring for the following group of clients. Select the client most likely to be diagnosed with respiratory alkalosis.
A 26-year-old female with anxiety who has been hyperventilating
Which hearing test would be prescribed to help differentiate conductive from sensorineural hearing loss?
A Weber (tuning fork) test
A nurse is providing care for several clients on an acute medicine unit. Which client should the nurse recognize as being at the highest risk for metabolic alkalosis?
A client on continuous nasogastric suction and whose hypertension is being treated with diuretics
Which persons are at high risk for developing ulcerative keratitis, an inflammation of the cornea? Select all that apply.
A client who uses extended-wear contact lenses A person who touched the fever blister and then rubbed the eye
Of the following clients, who would be at highest risk for developing hyperkalemia?
A male admitted for acute renal failure following a drug overdose
The nurse is caring for a pediatric client whose parent reports that the child has been pulling at her ears, has a fever, and has been crying more than usual. The nurse suspects the client may be experiencing which of the following?
Acute otitis media
The client is hospitalized for 4 days with an acute myocardial infarction. After a coronary artery stent is placed, the client is discharged to home in stable condition. This would be an example of which pattern of stress?
Acute time limited
A client's most recent laboratory results suggest the presence of metabolic alkalosis. What action by the nurse best addresses a potential cause of this acid-base imbalance?
Administering an antiemetic to treat the client's frequent vomiting
The nurse is caring for a client who has developed hypoxemia and tissue hypoxia. Which of these interventions does the nurse set as a priority intervention?
Administration of supplemental oxygen
As a nurse prepares to change a client's dressing, the client states that she is afraid that it will be painful. Noting that the client's heart rate and respiratory rate have increased, the nurse adjusts the plan of care to reflect care for a client in which phase of Selye's general adaptation syndrome?
Alarm
What is ocular muscle imbalance resulting in "lazy eye" called?
Amblyopia
The students are reviewing the anatomy of the eye and where the eye structures are located. Where is the anterior chamber located?
Anterior segment of the globe
The nurse is caring for an ex-soldier who has been diagnosed with posttraumatic stress disorder (PTSD). The nurse should prioritize which action?
Assessing the client for depression and risk for suicide
A health care provider suspects a client has developed posttraumatic stress disorder (PTSD). Select the necessary criterion to validate the diagnosis.
At least 1 month of clinically significant distress affecting a person after witnessing or experiencing a traumatic event that affects other parts of his or her life
The nurse is working at a first aid station in an amusement park. A 45-year-old client arrives reporting severe dizziness after a ride on the roller coaster. The nurse understands that a common cause of this sensation is:
Benign paroxysmal positional vertigo
A 26-year-old client who has recently traveled by airplane complains of pain in his right ear. The nurse suspects which condition?
Barotrauma
A young child has been diagnosed with amblyopia. The parents ask the nurse when treatment should be considered. At what age should treatment of children with the potential for development of amblyopia be instituted?
Before 6 years
The client has expressed a desire to explore stress-reducing strategies for chronic migraines. The provider explains one technique that involves electronic monitoring of physiologic responses to stress with immediate feedback. This is known as which of the following?
Biofeedback
An adult client has presented to the emergency department reporting symptoms of vertigo. Further assessment reveals that the client is ataxic and has facial weakness. The care team should consider which possible cause of this client's health problem?
Brain stem ischemia
Psychosocial factors can impact the body's response to stress either positively or negatively. It has been shown that social networks play a part in the psychosocial and physical integrity of a person. How do social networks affect how a body deals with stress?
By mobilizing the resources of the person
When caring for a client with hypomagnesemia, the nurse prioritizes assessment of which body system?
Cardiac
What is the uveal tract composed of? Select all that apply.
Choroid Ciliary body Iris
Which receptor type requires bright light for generation of nerve impulses?
Cones
A client has been diagnosed with bilateral cataracts associated with having difficulty seeing clearly. Reviewing the medication history, which drug may be responsible for the development of this condition?
Corticosteroids
Which of these is an endocrine regulator of pituitary and adrenal activity and a neurotransmitter involved in autonomic nervous system activity, metabolism, and behavior?
Corticotropin-releasing factor
A previously healthy 42-year-old client was recently diagnosed with hypertension. Which client activity will the nurse document as the best evidence the client is having a positive response to the stress of chronic illness?
Decreasing dietary sodium and fat intake
The nurse is caring for a client who has been diagnosed with presbycusis. The nurse understands that with this disorder, the client experiences which of the following?
Difficulty hearing high-pitched frequencies
Most physiologic control systems function under positive feedback mechanisms.
False
Vitreous humor occupies the posterior portion of the eyeball. It is an amorphous biologic gel. When liquefaction of the gel occurs, as in aging, what can be seen during head movement?
Floaters
The nurse is caring for a client with a tumor obstructing the lymphatic system. For which consequence does the nurse assess?
Fluid accumulating in the interstitial spaces distal to the tumor
A client in treatment for posttraumatic stress disorder is instructed to close the eyes and imagine being in a relaxing beach setting, smell a favorite food, and touch a handful of sand. Select the option that best describes the intervention.
Guided imagery
The nurse is aware that the major role of the kidneys in regulating acid-base balance is to increase the production of which chemical component?
HCO3-
Two people experience the same stressor, yet only one is able to cope and adapt adequately. Which term do physiologists use to describe this effect, which is correlated to positive health outcomes?
Hardiness
A nurse conducting a community education class on stress adaptation determines that the participants have understood the information when they state that a stable internal environment is called:
Homeostasis
A nurse is caring for an adolescent with posttraumatic stress syndrome. The client reports having difficulty concentrating and has an increased startle reflex. The nurse's documentation includes the presence of:
Hyperarousal
Respiratory alkalosis can be caused by a respiratory rate in excess of that which maintains normal plasma PCO2 levels. What is a common cause of respiratory alkalosis?
Hyperventilation
The nurse is caring for a client with ketoacidosis who is complaining of increasing lethargy and occasional confusion following several weeks of rigid adherence to a carbohydrate-free diet. The nurse understands which phenomenon is most likely occurring?
In the absence of carbohydrate energy sources, her body is metabolizing fat and releasing ketoacids.
The nurse is conducting a community education class on amblyopia. The nurse determines that the participants understand the concepts when they identify which time period as the time when amblyopia is generally diagnosed?
Infancy
A college student has just learned that her latest Papanicolaou test revealed atypical cells, a fact that has resulted in stress and an accompanying release of angiotensin II. How would the effects of this hormone be objectively manifested?
Increased blood pressure
What will the nurse assess as the end result of activation of the renin-angiotensin-aldosterone system?
Increased blood pressure
Which intervention is a priority for the nurse when caring for a client with hypokalemia?
Initiating cardiac monitoring
During an eye assessment the nurse notes inflammation of the client's cornea. The nurse should document this as which condition?
Keratitis
Amblyopia, or lazy eye, occurs at a time when visual deprivation or abnormal binocular interactions occur in visual infancy. Whether amblyopia is reversible depends on which factor?
Maturity of the visual system at time of onset.
The nurse is caring for a client who is interested in trying biofeedback to help improve the ability to cope with stress. Which information will the nurse provide the client about biofeedback techniques? Select all that apply.
Measuring muscle electrical responses can be used in biofeedback. Biofeedback is used to help gain better control over physiologic functioning. Measuring peripheral skin temperature can identify a physical response to anxiety.
A child accidentally consumes a container of wood alcohol. The ED physician knows that the child is at risk of developing which of the following?
Metabolic acidosis
A client tells the nurse that the client has been taking Alka-Seltzer (bicarbonate—antacid) four times a day for the past 2 weeks for an upset stomach. Upon assessment of the client, the nurse notes hyperactive reflexes, tetany, and mental confusion. Arterial blood gases reveal pH 7.55; serum HCO3− 37 mEq/L (37 mmol/L). The nurse suspects the client may be experiencing:
Metabolic alkalosis
Although stress exposure initiates integrated responses by multiple systems, the functional changes are first manifested in which body system?
Neuroendocrine
An older adult in an assisted care facility with documented presbyopia has lost his or her glasses. The nurse should instruct unlicensed assistive personnel that the client will need assistance with tasks that involve which part of sight?
Near vision
When thyroxine (T4) in the thyroid is low, it triggers the pituitary to increase thyroid stimulating hormone (TSH), which then increases T4 secretion. This is an example of which of the following?
Negative feedback mechanism
The manifestations of the stress response are strongly influenced by which system?
Nervous
The locus caeruleus (LC) is an area in the brain stem that produces which hormone?
Norepinephrine (NE)
A client has glaucoma. The nurse is taking a health history and knows that the most common form of glaucoma is which type?
Open angle
Water movement from the side of the membrane having a lesser number of particles and greater concentration of water to the side having a greater number of particles and lesser concentration of water is termed:
Osmosis
Conductive hearing loss can occur for a variety of reasons, including foreign bodies in the ear canal, damage to the ear drum, or disease. What disease is associated with conductive hearing loss?
Paget disease
Following several days in an acidotic state, a client has returned to desired pH. Which process could have contributed to the resolution of the client's health problem?
Phosphate and ammonia buffer systems in the renal tubules
Which visual deficit is a clinician justified in attributing to the normal aging process?
Presbyopia
With aging, progressive inelasticity and thickening of the lens causes which accommodation disorder?
Presbyopia
What is the nursing focus when the nurse performs a hearing test on a newborn infant?
Preventing developmental delays
A client develops diabetic ketoacidosis. What assessment indicates compensatory action?
Respirations deep at 30/min
An older adult client comes to the clinic complaining of seeing flashing lights and small spots. The client tells the nurse that this has been going on for over 24 hours but now it is as if there is a dark curtain whenever the client opens the eyes. The client asks the nurse if this means that blindness is imminent. What diagnosis should the nurse suspect?
Retinal detachment
A client expresses concern about feeling fullness in the ear. Which additional manifestation leads the health care provider to suspect Menière disease?
Rotary vertigo and tinnitus
The nurse is caring for an older adult client with a suspected diagnosis of presbycusis. Select the most likely manifestation.
Sensorineural hearing loss caused by natural aging
When a client reports that he feels like he is spinning but the room is stable, the nurse should document the finding as:
Subjective vertigo
A client's primary care provider has recommended biofeedback in an effort to address chronic stress and reduce the potential for complications. What will be the goal of this intervention?
Teaching the client to consciously control their own physiologic (body) functioning
The nurse is caring for a client who reports, "My ears are constantly ringing!" The nurse will evaluate the client further for the use of which medication?
acetylsalicylic acid (aspirin)
A client is admitted to the hospital with fluid volume deficit. The nurse should be aware that compensatory mechanisms will include:
activation of the renin-angiotensin-aldosterone system (RAAS).
The nurse is teaching a client about the treatment of open-angle glaucoma. The most appropriate information for the nurse to give the client would be:
administration of topical beta-adrenergic antagonists to lower the pressure.
A client, who travels frequently for work, reports intense ear pain during ascent from and descent into airports. The health care provider will recommend which category of medications to help alleviate this symptom?
decongestant nasal spray such as phenylephrine
The nurse is explaining to the parent of a 5-year-old that the child has otitis media with effusion (OME), noted by otoscopic exam, following an upper respiratory infection. Unlike acute otitis media (AOM), OME does not require treatment with antibiotics because it is usually:
asymptomatic and often self-limiting.
A client's chart documents the finding of cholesteatoma. The nurse interprets this to mean that the client has:
cystlike mass in the middle ear.
A client who has just completed running a marathon reports muscle weakness, cramping, and general fatigue despite drinking adequate amounts of water. The nurse suspects which type of hypotonic hyponatremia?
hypovolemic
The ophthalmologist is performing a client's annual eye exam and notes an increase in intraocular pressure. The condition most likely is the result of:
imbalance between aqueous production and outflow.
The nurse is performing her morning assessment on a 69-year-old client on a medical-surgical unit. Upon assessing her pupils the nurse notices that they are equal and responsive to light but not to accommodation. The nurse is aware that with aging the lens becomes thicker and its capsule less elastic so she believes this to be the case. When accommodation is diminished in an older person as a result of aging this is referred to as:
presbyopia
The nurse is caring for a client who is experiencing an increased level of aldosterone secretion. The nurse anticipates that the client may develop:
sodium and water retention.
The nurse understands that movement of otoliths may result in:
vertigo and nystagmus.
A client with a diagnosis of benign paroxysmal positional vertigo (BPPV) is receiving teaching from her physician about her diagnosis. The client is eager to avoid future episodes of vertigo and has asked the physician what she can do to prevent future episodes. How can the physician best respond?
"There are some exercises that I'll teach you to help reorient your inner ear and prevent vertigo."
A client has these arterial blood gas values: anion gap 20 mEq/L (20 mmol/L), pH 7.29, PCO2 37 mm Hg (4.92 mmol/L), HCO3- 11 mEq/L (11 mmol/L), base excess -6 mEq/L (-6 mmol/L). With what condition do these values correspond?
Lactic acidosis
The educator of a geriatric unit is orienting new staff and is teaching strategies on communicating with older adults with impaired hearing. Which teaching point is most appropriate?
"Ensure that the hearing aid is in place, turned on, and properly functioning."
A young child is flying on a plane for the first time. As the plane begins its descent for landing, the child's ears begin to hurt. The flight attendant sees that the child is in pain and tells the child to swallow until the pain goes away. Which structure is the child using to equalize the pressure and relieve the pain?
Swallowing pulls air through the Eustachian tubes, allowing the air pressure to equalize in the inner ear.
The parents of a 6-month-old child who was born with a blocked tear duct are concerned because their child has been waking up the past few mornings with inflammation in the left eye and yellow, dried secretions preventing eye opening in spite of massaging the tear duct. The nurse would anticipate which of the following?
The child has developed dacryocystitis.
