Exam 4 AC Flashcards
Fluid&Electrolytes Sensory Alterations Pschyosocial - self-concept, spititual health, culture, sexuality End-of-life Skeletalmuscule
Fluids and Electrolytes Questions
A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient’s pH value to be which of the following? a) 7.50 b) 7.30 c) 7.45 d) 7.35
a) 7.50 Explanation: The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive “blowing off” of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, Gram-negative bacteremia, and inappropriate ventilator settings.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching? a) “I can use laxatives and enemas but only once a week.” b) “A good breakfast for me will include milk and a couple of bananas.” c) “I will be sure to buy frozen vegetables when I grocery shop.” d) “I will take a potassium supplement daily as prescribed.”
a) “I can use laxatives and enemas but only once a week.” Explanation: The patient is experiencing hypokalemia most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum K+ level below 3.5 mEq/L [3.5 mmol/L], and usually indicates a deficit in total potassium stores. Patients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting, misuse of laxatives, diuretics, and enemas; thus, the patient should avoid laxatives and enemas. Prevention measures may involve encouraging the patient at risk to eat foods rich in potassium (when the diet allows) including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem.
When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Blood pressure 96/53 mm Hg b) Weight loss of 4 lb c) Mild confusion d) Irregular heart rate
d) Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, but following up on potential cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and hyponatremia, but following up on potential cardiac dysrhythmias is a higher priority. The blood pressure is slightly lower than normal but is not life threatening. Following up on potential cardiac dysrhythmias is a higher priority.
The nurse is caring for a patient with a serum potassium level of 6.0 mEq/L. The patient is ordered to receive oral sodium polystyrene sulfonate (Kayexelate) and furosemide (Lasix). What other orders should the nurse anticipate giving? a) Discontinue the IV lactated Ringer’s solution. b) Increase the rate of the IV lactated Ringer’s solution. c) Change the lactated Ringer’s solution to 3% saline. d) Change the lactated Ringer’s solution to 2.5% dextrose.
a) Discontinue the IV lactated Ringer’s solution. Explanation: The lactated Ringer’s IV fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer’s contains more sodium than daily requirements and excess sodium worsens fluid volume excess. Lactated Ringer’s also contains potassium, which would worsen the hyperkalemia.
The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? a) Anion gap b) Serum sodium level c) Bicarbonate level d) PaCO2
a) Anion gap Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8–12 mEq/L (8–12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12–16 mEq/L (12–16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.
A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hypocalcemia b) Hyponatremia c) Hypomagnesium d) Hypokalemia
Correct Response: d) Hypokalemia Explanation: Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Gastrointestinal (GI) loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia.
The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following? Select all that apply. a) Hematoma b) Air embolism c) Extravasation d) Phlebitis e) Infection
a) Hematoma , c) Extravasation , d) Phlebitis Explanation: Local complications of IV therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, febrile reaction, and infection.
The nurse is participating in the care of a patient who had a peripherally inserted central catheter (PICC) inserted in the right arm. Following catheter placement, the nurse should complete which of the following actions? a) Obtain written consent for the procedure. b) Assess the patient’s blood pressure (BP) on the right arm. c) Send the patient for a chest x-ray. d) Administer the prescribed IV fluids.
c) Send the patient for a chest x-ray. Explanation: A chest x-ray is needed to confirm the placement of catheter tip prior to initiation of ordered infusion. Consent should be obtained prior to the procedure, not after the procedure. No BPs should be taken on the extremity where the catheter is placed.
Which of the following arterial blood gas (ABG) results would the nurse anticipate for a patient with a 3-day history of vomiting? a) pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 b) pH: 7.55, PaCO2: 60 mm Hg, HCO3–: 28 c) pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d) pH: 7.45, PaCO2: 32 mm Hg, HCO3–: 21
Correct Response: b) pH: 7.55, PaCO2: 60 mm Hg, HCO3–: 28 Explanation: The patient’s ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.
The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? a) Prolonged PR intervals b) Prolonged QT intervals c) Elevated ST segments d) Peaked T waves
a) Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium level.
A nurse is caring for a patient with acute renal failure and hypernatremia. Which of the following actions can be delegated to the nursing assistant? a) Monitor for signs and symptoms of dehydration. b) Teach the patient about increased fluid intake. c) Assess the patient’s daily weights for trends. d) Provide oral care every 2–3 hours.
d) Provide oral care every 2–3 hours. Explanation: Providing oral care for the patient every 23 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient’s serum sodium value would be which of the following? a) 155 mEq/L b) 145 mEq/L c) 135 mEq/L d) 125 mEq/L
Correct Response: a) 155 mEq/L Explanation: The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) Lactated Ringer’s solution b) 5% NaCl c) 0.45% NaCl d) 0.9% NaCl
c) 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer’s solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a) pH: 7.32, PaCO2: 40 mm Hg, HCO3–: 18 mEq/L b) pH: 7.42, PaCO2: 45 mm Hg, HCO3–: 22 mEq /L c) pH: 7.20, PaCO2: 65 mm Hg, HCO3–: 26 mEq/L d) pH: 7.50, PaCO2: 30 mm Hg, HCO3–: 24 mEq/L
c) pH: 7.20, PaCO2: 65 mm Hg, HCO3–: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3– occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3– : 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3– : 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3– : 22 mEq/L indicate a normal result/no imbalance.
A patient with a magnesium level of 2.6 mEq/L is being treated on a medical-surgical unit. Which of the following treatments should the nurse anticipate will be used? a) Dialysis b) Fluid restriction c) IV furosemide (Lasix) d) Oral magnesium oxide (MagOx)
c) IV furosemide (Lasix) Explanation: The nurse should anticipate the administration of Lasix for the treatment of hypermagnesemia. Administration of loop diuretics (e.g., furosemide) and sodium chloride or lactated Ringer’s IV solution enhances magnesium excretion in patients with adequate renal function. Fluid restriction is contraindicated. The patient should be encouraged to increase fluids to promote the excretion magnesium by way of the urine. MagOx is contraindicated as it would further elevate the patient’s serum magnesium level. In acute emergencies, when the magnesium level is severely elevated, hemodialysis with a magnesium-free dialysate can reduce the serum magnesium to a safe level within hours.
The nurse is assigned to care for a patient with a serum phosphorus level of 5.0 mg/dL. The nurse anticipates that the patient will also experience which of the following electrolyte imbalances? a) Hypermagnesemia b) Hyponatremia c) Hypocalcemia d) Hyperchloremia
c) Hypocalcemia Explanation: The patient is experiencing an elevated serum phosphorus level. Hyperphosphatemia is defined as a serum phosphorus level that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus level tends to cause a low serum calcium concentration.
The nurse is caring for a patient diagnosed with hyperchloremia. Signs and symptoms of hyperchloremia include which of the following? Select all that apply. a) Dehydration b) Hypotension c) Lethargy d) Weakness e) Tachypnea
c) Lethargy , d) Weakness , e) Tachypnea Explanation: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention.
The nurse has been assigned to care for the following patients. Which patient is at the highest risk for a fluid and electrolyte imbalance? a) A 79-year-old man admitted with a diagnosis of pneumonia. b) A 66-year-old woman who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. c) A 45-year-old man who had a laparoscopic appendectomy 24 hours ago being advanced to a regular diet. d) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex).
d) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). Explanation: The 82-year-old patient has three risk factors: advanced age, tube feedings, and diuretic usage (Demadex). This patient has the highest risk for fluid and electrolyte imbalances. The 45-year-old man has the risk factor of surgery but is not the patient at the highest risk. The 79-year-old patient has the risk factor of advanced age but is not the patient at the highest risk. The 66-year-old patient has the risk factors of age and the bile drain but is not the patient at the highest risk.
The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Hallucinations b) Nausea c) Confusion d) Headache
c) Confusion Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L. Hyponatremia exists when the serum level decreases below 135 mEq/L, there is. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium levels.
A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient’s serum calcium level is 12.3 mg/ dL. Given this laboratory finding, the nurse should suspect which of the following statements? a) The patient’s diet is lacking in calcium-rich food products. b) The patient may be developing hyperaldosteronism. c) The patient’s malignancy is causing the electrolyte imbalance. d) The patient has a history of alcohol abuse.
c) The patient’s malignancy is causing the electrolyte imbalance. Explanation: The patient’s laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium level greater than 10.2 mg/dL (2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia by a variety of mechanisms. The patient’s calcium level is elevated; there is no indication that the patient’s diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient’s serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance? a) Negative Chvostek’s sign b) Slurred speech c) Presence of Trousseau’s sign d) Muscle weakness
c) Presence of Trousseau’s sign Explanation: A patient status post radical neck resection is prone to developing hypocalcemia. Hypocalcemia is defined as a serum values lower than 8.6 mg/dL [2.15 mmol/L]. Signs and symptoms of hypocalcemia include: Chvostek’s sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped, and a positive Trousseau’s sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.
The nurse is caring for a patient with severe diarrhea. The nurse recognizes that the patient is at-risk for developing which of the following acid-base imbalances? a) Metabolic acidosis b) Respiratory alkalosis c) Respiratory acidosis d) Metabolic alkalosis
a) Metabolic acidosis Explanation: The patient is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
The nurse is instructing a patient with recurrent hyperkalemia about following a potassium-restricted diet. Which of the following patient statements indicates the need for additional instruction? a) “I need to check if my cola beverage has potassium in it.” b) “I’ll drink cranberry juice with my breakfast instead of coffee.” c) “Bananas have a lot of potassium in them, I’ll stop buying them.” d) “I will not salt my food, instead I’ll use salt substitute.”
d) “I will not salt my food, instead I’ll use salt substitute.” Explanation: The patient should avoid salt substitutes. The nurse must caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.
The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Strength testing for muscle wasting b) Blood pressure, heart rate, and rhythm c) Intake and output, urine volume, and color d) Skin assessment for edema and turgor e) Nutritional status and diet
b) Blood pressure, heart rate, and rhythm , c) Intake and output, urine volume, and color , d) Skin assessment for edema and turgor Explanation: To assess for FVE the nurse measures: blood pressure, heart rate and rhythm, breath sounds, skin assessment for edema and turgor, inspection of neck veins, intake and output, daily weights, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess.
The nurse is caring for a patient undergoing alcohol withdrawal. Which of the following serum laboratory values should the nurse monitor most closely? a) Potassium b) Calcium c) Magnesium d) Phosphorus
c) Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium level should be measured at least every 2 or 3 days in patients undergoing alcohol withdrawal. The serum magnesium level may be normal on admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with IV glucose administration.
Sensory Alterations Questions
To avoid the side effects of corticosteroids, which of the following medication classifications is used as an alternative to treating inflammatory conditions of the eyes?
a)
Miotics
b)
Nonsteroidal anti-inflamatory drugs (NSAIDS)
c)
Cycloplegics
d)
Mydriatics
b)
Nonsteroidal anti-inflamatory drugs (NSAIDS)
Explanation:
NSAIDS are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.
A patient is diagnosed with a corneal abrasion and the nurse has administered proparacaine hydrochloride (Ophthaine 0.5%) per orders to assess visual acuity. The patient requests a prescription for this medication because it completely took away the pain. What is the best response by the nurse?
a)
“It is standard for the doctor to write a prescription for this medication.”
b)
“Usually we will send you home with this bottle and written instructions for administering the medication.”
c)
“I will let the doctor know.”
d)
“Prescriptions of this medication are generally not given because it can cause corneal problems.”
d)
“Prescriptions of this medication are generally not given because it can cause corneal problems.”
Explanation:
Proparacaine hydrochloride (Ophthaine 0.5%) can cause corneal softening and other complications if overused. Patients with corneal abrasions or other painful eye disorders have a tendency to overuse the medication, thus leading to the complications. It would not be appropriate to give the bottle with written instructions and it is not a standard prescription for eye disorders because of the complications from overuse. Telling the patient that you will let the doctor know does not provide the education needed about this medication.
The nurse is explaining metastatic rhabdomyosarcoma to a group of parents with children diagnosed with the disease. The most common site of metastasis in patients diagnosed with rhabdomyosarcoma is which of the following?
a)
Lymph nodes
b)
Bone
c)
Lung
d)
Brain
c)
Lung
Explanation:
The most common site of metastasis in patients diagnosed with rhabdomyosarcoma is the lung. The brain, bone, and lymph nodes are not common sites of the metastasis in this type of tumor.
Which of the following is an accurate statement regarding refractive surgery?
a)
Refractive surgery may be performed on patients with an abnormal corneal structure as long as they have a stable refractive error.
b)
Refractive surgery will alter the normal aging of the eye.
c)
Refractive surgery is an elective cosmetic surgery performed to reshape the cornea.
d)
Refractive surgery may be performed on all patients, even if they have underlying health conditions.
c)
Refractive surgery is an elective cosmetic surgery performed to reshape the cornea.
Explanation:
Refractive surgery is an elective procedure; it is considered a cosmetic procedure (to achieve clear vision without the aid of prosthetic devices). It is performed to reshape the cornea to correct all refractive errors. Refractive surgery will not alter the normal aging process of the eye. Patients with conditions that are likely to affect corneal wound healing adversely (corticosteroid use, immunosuppression, elevated intraocular pressure [IOP]) are not good candidates for the procedure. The corneal structure must be normal and the refractive error stable.
Which group of medications causes pupillary constriction?
a)
Mydriatics
b)
Adrenergic agonists
c)
Beta-blockers
d)
Miotics
d)
Miotics
Explanation:
Miotics cause pupillary constriction. Mydriatics cause pupillary dilation. Beta-blockers decrease aqueous humor production. Adrenergic agonists increase aqueous outflow, but primarily decrease aqueous production with an action similar to beta-blockers and carbonic anhydrase inhibitors.
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry red in color?
a)
Molluscum contagiosum
b)
Milia
c)
Hemangioma
d)
Xanthelasma
c)
Hemangioma
Explanation:
Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye that commonly appear as a result of skin aging or a lipid disorder. Molluscum contagiosum lesions are flat, symmetric growths along the lid margin caused by a virus that can result in conjunctivitis and keratitis if the lesion grows into the conjunctival sac.
The nurse should monitor for which of the following manifestations in a patient who has had LASIK surgery?
a)
Halos and glare
b)
Stye formation
c)
Cataract formation
d)
Excessive tearing
a)
Halos and glare
Explanation:
After LASIK surgery, symptoms of central islands and decentered ablations can occur that include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.
Which medication classifications increases aqueous fluid outflow in the patient with glaucoma?
a)
Alpha-adrenergic agonists
b)
Beta-blockers
c)
Carbonic anhydrase inhibitors
d)
Cholinergics
d)
Cholinergics
Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis and opening the trabecular meshwork. Beta-blockers decrease aqueous humor production. Alpha-adrenergic agonists decrease aqueous humor production. Carbonic anhydrase inhibitors decrease aqueous humor production.
Which of the following should the nurse recommend to a patient with blepharitis?
a)
Sleeping with the face parallel to the floor
b)
Incision and drainage
c)
Warm soaks of the area
d)
Keeping lid margins clean
d)
Keeping lid margins clean
Explanation:
Instructions on lid hygiene (to keep the lid margins clean and free of exudates) are given to the patient. Treatment of a stye includes warm soaks of the area, incision, and drainage. The patient is not required to sleep with the face parallel to the floor.
The nurse is assessing visual acuity via a Snellen chart. The patient states he cannot read the letter at the top of the chart. What action should the nurse do next?
a)
Obtain a tumbling “E” chart to assess visual acuity.
b)
Document the findings.
c)
Complete an internal eye examination.
d)
Determine if the patient can count fingers.
d)
Determine if the patient can count fingers.
Explanation:
If the patient cannot read the top letter of the Snellen chart, then the nurse needs to determine if the patient can count fingers. If the patient can count fingers, then the nurse will hold up a random number of fingers, starting at 5-foot intervals, moving forward until the patient can clearly count the fingers. A complete visual acuity assessment should be completed before the findings are documented. The tumbling “E” chart is administered in the same fashion as the Snellen chart and is used for people who are illiterate or cannot read the English alphabet. The nurse should not complete an internal eye examination as the next action.
Which of the following types of glaucoma presents an ocular emergency?
a)
Ocular hypertension
b)
Acute angle-closure glaucoma
c)
Chronic open-angle glaucoma
d)
Normal tension glaucoma
b)
Acute angle-closure glaucoma
Explanation:
Acute angle-closure glaucoma results in rapid, progressive visual impairment. Normal tension glaucoma is treated with topical medication. Ocular hypertension is treated with topical medication. Chronic open-angle glaucoma is treated initially with topical medications, with oral medications added later.
Which of the following is the most common cause of visual loss in people older than 65 years of age?
a)
Glaucoma
b)
Macular degeneration
c)
Retinal detachment
d)
Cataracts
b)
Macular degeneration
Explanation:
Macular degeneration is the most common cause of visual loss in people older than 65 years of age
A nurse is caring for a patient scheduled to have angiography of the right eye in 1 hour. What is the highest priority nursing intervention?
a)
Instruct the patient to hold head still during procedure.
b)
Assess blood urea nitrogen (BUN) and creatinine levels.
c)
Educate the patient about the feeling of warmth and metallic taste that may occur during the procedure.
d)
Assess for dark yellow to orange urine.
b)
Assess blood urea nitrogen (BUN) and creatinine levels.
Explanation:
The nurse should assess the BUN and creatinine levels to ensure the patient has adequate renal function to excrete the contrast used. Inability to excrete the contrast could lead to complications. Instructing the patient to hold his or her head still and educating about the feeling of warmth and metallic taste are appropriate interventions; assessing renal function remains the highest priority. Assessing for dark yellow to orange urine is appropriate in the postprocedural timeframe so it would not be the highest priority.
Which of the following surgical procedures involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?
a)
Keratoplasty
b)
Laser-assisted stromal in situ keratomileusis (LASIK)
c)
Keratoconus
d)
Photorefractive keratectomy (PRK)
b)
Laser-assisted stromal in situ keratomileusis (LASIK)
Explanation:
LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue.
A patient is diagnosed with a corneal abrasion and the nurse has administered proparacaine hydrochloride (Ophthaine 0.5%) per orders to assess visual acuity. The patient requests a prescription for this medication because it completely took away the pain. What is the best response by the nurse?
a)
“I will let the doctor know.”
b)
“It is standard for the doctor to write a prescription for this medication.”
c)
“Usually we will send you home with this bottle and written instructions for administering the medication.”
d)
“Prescriptions of this medication are generally not given because it can cause corneal problems.”
d)
“Prescriptions of this medication are generally not given because it can cause corneal problems.”
Explanation:
Proparacaine hydrochloride (Ophthaine 0.5%) can cause corneal softening and other complications if overused. Patients with corneal abrasions or other painful eye disorders have a tendency to overuse the medication, thus leading to the complications. It would not be appropriate to give the bottle with written instructions and it is not a standard prescription for eye disorders because of the complications from overuse. Telling the patient that you will let the doctor know does not provide the education needed about this medication.
A patient was hit in the eye with a stick. The nurse notes edema to the conjunctiva. What documentation by the nurse describes the assessment findings?
d)
Chemosis
Explanation:
Chemosis is a common manifestation of pinkeye. Papilledema refers to swelling of the optic disk due to increased intracranial pressure. Proptosis is the downward displacement of the eyeball. Strabismus is a condition in which there is a deviation from perfect ocular alignment.
Which of the following would be an accurate clinical manifestation of a retinal detachment?
a)
Chemosis and redness of the sclera
b)
Bright flashing lights
c)
Sudden onset of intense pain
d)
Colored halos around lights
b)
Bright flashing lights
Explanation:
Patients can complain of bright flashing lights as a clinical manifestation of retinal detachment. Patients do not complain of pain with retinal detachment. Colored halos around lights is specific to glaucoma. Chemosis does not usually occur with retinal detachment.
The nurse is explaining metastatic rhabdomyosarcoma to a group of parents with children diagnosed with the disease. The most common site of metastasis in patients diagnosed with rhabdomyosarcoma is which of the following?
a)
Lung
b)
Brain
c)
Lymph nodes
d)
Bone
a)
Lung
Explanation:
The most common site of metastasis in patients diagnosed with rhabdomyosarcoma is the lung. The brain, bone, and lymph nodes are not common sites of the metastasis in this type of tumor.
The nurse is demonstrating how to perform punctal occlusion. Which of the following activities does the nurse perform?
a)
Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye
b)
Holds down the lower lid of the eye by applying pressure on the eyeball and the cheekbone
c)
Applies gentle pressure to the upper eyelid to keep the lid open while telling the patient to gaze upward
d)
Firmly applies pressure to the upper and lower eyelids at outer edges to keep eyelids in approximation
a)
Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye
Explanation:
Punctal occlusion is done by applying gentle pressure to the inner canthus of each eye for 1 to 2 minutes immediately after eye drops are instilled. The nurse does not apply pressure to the eyeball when administering medications. The lower eyelid is held down to expose the conjunctival sac. The other action described will not aid in the retention or absorption of medication.
A patient has been prescribed eye drops for the treatment of glaucoma. At the yearly follow-up appointment, the patient tells the nurse that she has stopped using the medication because her vision did not improve. Which of the following is the appropriate action to be taken by the nurse?
a)
Refer the patient to the ED.
b)
Administer the medication immediately.
c)
Talk with the doctor about switching to a different glaucoma medication.
d)
Explain the therapeutic effect and expected outcome of the medication.
d)
Explain the therapeutic effect and expected outcome of the medication.
Explanation:
The nurse needs to explain the therapeutic effect and expected outcome of the medication. The medication is not a cure for glaucoma, but can slow the progression. The patient will not see improvements in his or her vision with the use of the medication, but should see little to no deterioration of vision. The doctor may choose to switch the medication, but not because the vision is not improving; it would be based on not obtaining the set intraocular pressure (IOP). Administering the medication immediately or referring the patient to the ED is not appropriate because this is not an emergent situation.
A patient’s vision is assessed at 20/200. The patient asks what that means. Which of the following is the most appropriate response by the nurse?
a)
“You see an object from 20 feet away that a person with normal vision sees from 20 feet away.”
b)
“You see an object from 20 feet away that a person with normal vision sees from 200 feet away.”
c)
“You see an object from 200 feet away that a person with normal vision sees from 20 feet away.”
d)
“You see an object from 200 feet away that a person with normal vision sees from 200 feet away.”
b)
“You see an object from 20 feet away that a person with normal vision sees from 200 feet away.”
Explanation:
The fraction 20/20 is considered the standard of normal vision. Most people, positioned 20 feet from the eye chart, can see the letters designated as 20/20 from a distance of 20 feet.
Which of the following terms refers to the absence of the natural lens?
a)
Hyphema
b)
Keratoconus
c)
Scotoma
d)
Aphakia
d)
Aphakia
Explanation:
When a cataract is extracted, and an intraocular lens implant is not used, the patient demonstrates aphakia. Scotoma refers to a blind or partially blind area in the visual field. Keratoconus refers to a cone-shaped deformity of the cornea. Hyphema refers to blood in the anterior chamber of the eye.
Which is the term for swelling of the optic disc due to increased intraocular pressure (IOP)?
a)
Chemosis
b)
Photophobia
c)
Papilledema
d)
Ptosis
c)
Papilledema
Explanation:
Papilledema is swelling of the optic disc due to increased IOP. Chemosis is edema of the conjunctiva. Ptosis is a drooping eyelid. Photophobia is ocular pain on exposure to light.
Which of the following would not be included as a marker of medication effectiveness in glaucoma control?
a)
Lowering intraocular pressure (IOP) to target pressure
b)
Visual field
c)
Opacity of the lens
d)
Appearance of optic nerve head
c)
Opacity of the lens
Explanation:
Opacity of the lens relates to cataract formation. The main markers of the efficacy of the medication in glaucoma control are lowering of the IOP to the target pressure, appearance of the optic nerve head, and the visual field.
The nurse is preparing a presentation for a group of older adults on the topic open-angle glaucoma. Which of the following symptoms would be included as indications of open-angle glaucoma? Select all that apply.
a)
Halos around lights
b)
Decreasing peripheral vision
c)
Blurred vision
d)
Bright flashing lights
e)
Severe pain
f)
Difficulty adjusting eyes in low lighting
a)
Halos around lights
, b)
Decreasing peripheral vision
, c)
Blurred vision
, f)
Difficulty adjusting eyes in low lighting
Explanation:
Decreased peripheral vision, difficulty adjusting eyes in low lighting, halos, and blurred vision are typical symptoms of open-angle glaucoma. Bright flashes of light may be an indication of retinal detachment. Severe pain is usually associated with angle-closure glaucoma or eye trauma.
A patient presents to the ED complaining of a chemical burn to both eyes. Which of the following is the priority nursing intervention?
a)
Assess visual acuity.
b)
Irrigate both eyes.
c)
Assess the pH of the corneal surface.
d)
Obtain the Material Safety Data Sheet (MSDS).
b)
Irrigate both eyes.
Explanation:
The eyes should immediately be irrigated to remove the chemical and preserve the eye. If the chemical is allowed to remain on the eye surface, it may cause ulcerations and permanent damage to the eye. It is appropriate to obtain the MSDS and assess the pH of the corneal surface after irrigation has begun. Irrigation should continue until the pH normalizes. Visual acuity can be assessed once the emergent phase is over.
Which of the following would not be included as a marker of medication effectiveness in glaucoma control?
a)
Appearance of optic nerve head
b)
Visual field
c)
Opacity of the lens
d)
Lowering intraocular pressure (IOP) to target pressure
c)
Opacity of the lens
Explanation:
Opacity of the lens relates to cataract formation. The main markers of the efficacy of the medication in glaucoma control are lowering of the IOP to the target pressure, appearance of the optic nerve head, and the visual field.
The nurse just completed educating a patient on hearing aid care. Which statement by the patient indicates that the teaching was effective?
a)
“I will notify the hearing aid dealer if the hearing aid whistles.”
b)
“I will dry my ears with a cotton-tip applicator before inserting the hearing aid.”
c)
“I will wash the entire hearing aid daily with soap and water.”
d)
“I will use a small pipe cleaner to clean the cannula on the hearing aid.”
)
“I will use a small pipe cleaner to clean the cannula on the hearing aid.”
Explanation:
Only the ear mold should be cleaned daily using soap and water, no other part of the hearing aid should be cleaned with soap and water. The patient should be taught troubleshooting if the hearing aid whistles. Many times the patient can fix the issue when the hearing aid whistles. The ears should not be dried using a cotton-tip applicator because it can cause trauma and lead to otitis externa. The cannula on the hearing aid should be cleaned with a small pipe cleaner or pipe cleaner-like object.
Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?
a)
Otosclerosis
b)
Chronic otitis media
c)
Otitis externa
d)
Middle ear effusion
a)
Otosclerosis
Explanation:
Otosclerosis is more common in females than males and is frequently hereditary. A middle ear effusion is denoted by fluid in the middle ear without evidence of infection. Chronic otitis media is defined as repeated episodes of acute otitis media causing irreversible tissue damage and persistent tympanic membrane perforation. Otitis externa refers to inflammation of the external auditory canal.
Which of the following is consistent with acute otitis media?
a)
Conductive hearing loss may occur.
b)
The infection usually lasts more than 6 weeks.
c)
It is usually caused by a fungal infection.
d)
It is a relatively uncommon childhood infection.
a)
Conductive hearing loss may occur.
Explanation:
Approximately three of four children experience an ear infection by the time they are 3 years of age. The infection usually lasts less than 6 weeks. Conductive hearing loss may occur due to a purulent exudate. Bacteria and viruses are the most common causes of otitis media, not fungi.
Which of the following terms refers to altered sensation of orientation in space?
a)
Vertigo
b)
Dizziness
c)
Tinnitus
d)
Nystagmus
b)
Dizziness
Explanation:
Dizziness may be associated with inner ear disturbances. Vertigo is the illusion of movement where the individual or the surroundings are sensed as moving. Tinnitus refers to a subjective perception of sound with internal origin. Nystagmus refers to involuntary rhythmic eye movement.
Which of the following statements correctly matches the nursing diagnosis with its appropriate nursing intervention for a patient suffering with vertigo? Select all that apply.
a)
Powerlessness: Provide a daily schedule of activities.
b)
Anxiety: Provide information about vertigo and its treatment.
c)
Risk for deficient fluid volume intake: Encourage oral fluids.
d)
Risk for injury: Encourage vestibular therapy.
e)
Risk for trauma: Assist with ambulation.
b)
Anxiety: Provide information about vertigo and its treatment.
, c)
Risk for deficient fluid volume intake: Encourage oral fluids.
, d)
Risk for injury: Encourage vestibular therapy.
, e)
Risk for trauma: Assist with ambulation.
Explanation:
A patient with vertigo is at risk for deficient fluid volume and should be encouraged to drink non-caffeinated and low sugar fluids. A patient with vertigo is at risk for injury and encouraging the patient to do vestibular therapy can decrease the risk for injury. The patient with vertigo is also at risk for trauma and should have assistance when ambulating. Providing information about vertigo and its treatment may decrease the anxiety in a patient with vertigo. The nurse is contributing to the feeling of powerlessness if providing a daily schedule of activities. The patient should be allowed to participate in determining his or her schedule.
Which action by the nurse has the highest priority when caring for a patient diagnosed with vertigo?
a)
Encourage the patient to stare straight ahead, focusing on one object.
b)
Administer antivertiginous medication as ordered.
c)
Educate the patient on using the call light for assistance with ambulation.
d)
Encourage the patient to keep his or her eyes open.
c)
Educate the patient on using the call light for assistance with ambulation.
Explanation:
The patient should restrict movement and change positions slowly to prevent an injury related to the vertigo. The prevention of injury related to the vertigo should be the highest priority nursing intervention; therefore, the nurse needs to teach the patient about using the call light for assistance with ambulation. All other interventions are appropriate, but do not address safety. The patient should keep his or her eyes open and look at one place to reduce vertigo.
The nurse is caring for an 86-year-old patient with hearing impairment. The nurse is preparing to educate the patient on the diagnosis and discharge plan. What action(s) should the nurse take when talking with the patient? Select all that apply.
a)
Speak in loud, high-pitched tones.
b)
Ensure adequate lighting by standing in front of the uncovered window.
c)
Ensure written material is at an eighth-grade level.
d)
Always face the patient when talking.
e)
Provide written instructions and information.
d)
Always face the patient when talking.
, e)
Provide written instructions and information.
Explanation:
The nurse should always face the patient who is hearing impaired when talking. The nurse should provide written instructions and information based on a third-grade reading level, not an eighth-grade level. Older adults lose the ability to hear high-pitched tones first; therefore speaking loudly in high-pitched tones will not help with communication for this patient. Standing in front of a window can place a shadow on the nurse’s face, not allowing the patient to see the nurse’s face or read lips.
It is important for the nurse to educate patients newly diagnosed with Ménière’s disease to avoid which of the following in their diet? Select all that apply.
a)
Whole grains
b)
Caffeine
c)
Milk
d)
High-salt foods
e)
Monosodium glutamate
f)
Alcohol
g)
Spicy food
b)
Caffeine
, d)
High-salt foods
, e)
Monosodium glutamate
, f)
Alcohol
Explanation:
Alcohol, high salt, monosodium glutamate, and caffeine can worsen symptoms of Ménière’s disease by affecting the fluid levels in the inner ears. There are no restrictions on spicy food for patients displaying symptoms of Ménière’s disease. Milk and whole grains are encouraged in a patient diagnosed with Ménière’s disease.
Which portion of the middle ear equalizes pressure?
a)
Eustachian tube
b)
Cochlea
c)
Ossicles
d)
Auricle
a)
Eustachian tube
Explanation:
The Eustachian tube drains secretions of the middle ear and equalizes pressure in the middle ear with that of the atmosphere. Ossicles, which are held in place by joints, muscles, and ligaments, assist in the transmission of sound. The auricle collects the sound waves and directs vibrations into the external auditory canal. The cochlea is a winding, snail-shaped bony tube that forms a portion of the inner ear and contains the organ of Corti, which is the transducer of hearing.
Loud, persistent noise has what effect on the body?
a)
Decreased heart rate
b)
Increased blood pressure
c)
Decreased gastrointestinal activity
d)
Dilation of peripheral blood vessels
b)
Increased blood pressure
Explanation:
Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased BP, increased heart rate, and increased GI motility.
Which of the following is a symptom related to vertigo?
a)
Syncope
b)
Loss of consciousness
c)
Fainting
d)
Spinning sensation
d)
Spinning sensation
Explanation:
Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them. Fainting, syncope, and loss of consciousness are not symptoms of vertigo, but are issues with another body system.
A patient is diagnosed with otitis externa. Which of the following instructions is most appropriate for the nurse to give?
a)
Avoid using cold water when shampooing hair.
b)
Keep the ear covered with a scarf.
c)
Avoid swimming for 7 to 10 days.
d)
Keep a dry cotton ball in the ear canal.
c)
Avoid swimming for 7 to 10 days.
Explanation:
The nurse should advise the patient to avoid swimming for 7 to 10 days to allow the ear canal to heal completely. Keeping the ear covered with a scarf is not necessary. Keeping a dry cotton ball in the ear may cause further trauma to the ear canal. A cotton ball covered in a water-soluble solution can be used to keep water out while showering or washing hair. Avoiding cold water does not help to improve the patient’s condition.
Which terms refers to the progressive hearing loss associated with aging?
a)
Sensorineural hearing loss
b)
Presbycusis
c)
Exostoses
d)
Otalgia
b)
Presbycusis
Explanation:
Presbycusis is the gradual loss of hearing common to many older adults. Both middle and inner ear age-related changes result in hearing loss. Exostoses are small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.
Which of the following manifestations is most problematic for the patient diagnosed with Ménière’s disease?
a)
Vertigo
b)
Hearing loss
c)
Diaphoresis
d)
Tinnitus
)
Vertigo
Explanation:
Vertigo is usually the most troublesome complaint related to Ménière’s disease. Other clinical manifestations may include tinnitus, diaphoresis, and hearing loss.
A patient undergoing mastoid surgery asks the nurse about the pain following the surgery. Which of the following responses by the nurse is appropriate?
a)
“The incisional pain usually last 3 weeks. The doctor will make sure you have enough pain medications.”
b)
“Most patients report a sharp shooting pain for 1 to 2 months following the surgery from the Eustachian tube opening.”
c)
“Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours.”
d)
“Usually there is a constant throbbing pain for the first week. Most patients report no pain with the use of the pain
)
“Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours.”
Explanation:
The incisional pain from mastoid surgery is usually mild and controlled by prescribed pain medications. The patient should be taking medications routinely the first 24 hours and, as needed, after 24 hours. Incisional pain usually does not last 3 weeks. The patient may feel a sharp shooting pain when the Eustachian tube is open for 2 to 3 weeks following surgery. A constant throbbing pain may indicate an infection and should be investigated.
Which statement describes benign paroxysmal positional vertigo (BPPV)?
a)
BPPV is caused by tympanic membrane rupture.
b)
The vertigo is usually accompanied by nausea and vomiting.
c)
BPPV is stimulated by the use of certain medication such as acetaminophen.
d)
The onset of BPPV is gradual.
b)
The vertigo is usually accompanied by nausea and vomiting.
Explanation:
BPPV is a brief period of incapacitating vertigo that occurs when the position of the patient’s head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however, hearing impairment does not generally occur. The onset of BPPV is sudden and followed by a predisposition for positional vertigo, usually for hours to weeks, but occasionally for months or years. BPPV is thought to be caused by the disruption of debris within the semicircular canal. This debris is formed from small crystals of calcium carbonate from the inner ear structure, the utricle. BPPV is frequently stimulated by head trauma, infection, or other events.
78-year-old patient complains of decreased hearing in the right ear. The doctor orders irrigation to the right ear for cerumen removal. Which of the following is the priority action by the nurse?
a)
Protecting the patient’s clothing from getting wet
b)
Ensuring that warm water is used for irrigation
c)
Using gentle pressure behind the cerumen impaction
d)
Assessing for a ruptured tympanic membrane
d)
Assessing for a ruptured tympanic membrane
Explanation:
The ear should not be irrigated if the patient has a ruptured tympanic membrane or otitis externa. All other interventions are appropriate when irrigating the ear, but if the patient has a ruptured tympanic membrane the nurse should not irrigate the ear.
Which of the following is a definition of ossiculoplasty?
a)
Incision into the tympanic membrane
b)
Surgical repair of the eardrums
c)
Incision into the eardrum
d)
Surgical reconstruction of the middle ear bones
d)
Surgical reconstruction of the middle ear bones
Explanation:
Ossiculoplasty is performed to restore hearing. Surgical repair of the eardrum is termed tympanoplasty. Tympanotomy or myringotomy is the term used to refer to incision into the tympanic membrane.
A patient newly diagnosed with otitis media reports the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse?
a)
Document effectiveness of medications.
b)
Irrigate the ear.
c)
Educate on therapeutic effects of medications.
d)
Assess tympanic membrane.
d)
Assess tympanic membrane.
Explanation:
The sudden relief of pain and/or pressure in a patient diagnosed with otitis media should be assessed for a tympanic membrane rupture. Educating the patient on the therapeutic effects of the medications is appropriate for newly diagnosed otitis media, but does not address the sudden disappearance of pain and pressure. Because the medication usually takes 48 to 72 hours to be effective, documenting the medication as effective would be inappropriate. It is not necessary to irrigate an ear with otitis media.
High doses of which of the following medications can produce bilateral tinnitus?
a)
Antivert
b)
Promethazine
c)
Dramamine
d)
Aspirin
d)
Aspirin
Explanation:
At high doses, aspirin toxicity can produce bilateral tinnitus. Antivert and Dramamine are used for nausea and vomiting related to motion sickness. Antiemetics, such as promethazine (Phenergan) suppositories, help control the nausea and vomiting and the vertigo because of the antihistamine effect.
If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone causing what effect?
a)
Facial nerve paralysis
b)
Nystagmus
c)
Motor impairment
d)
Diplopia
a)
Facial nerve paralysis
Explanation:
If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.
Which of the following terms refers to surgical repair of the tympanic membrane?
a)
Ossiculoplasty
b)
Tympanotomy
c)
Myringotomy
d)
Tympanoplasty
d)
Tympanoplasty
Explanation:
Tympanoplasty may be necessary to repair a scarred eardrum. A tympanotomy is an incision into the tympanic membrane. A myringotomy is an incision into the tympanic membrane. Ossiculoplasty is surgical reconstruction of the middle ear bones to restore hearing.
Which of the following tests uses a tuning fork between two positions to assess hearing?
a)
Watch tick
b)
Rinne
c)
Weber
d)
Whisper
b)
Rinne
Explanation:
In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air and bone conduction of sound. The whisper test involves covering the untested ear and, whispering from a distance of 1 or 2 feet from the nonoccluded ear, tests the ability of the patient to repeat what was whispered. The watch tick test relies on the ability of the patient to perceive the high-pitched sound made by a watch held at the patient’s auricle. The Weber test uses bone conduction to test lateralization of sound.
A patient is newly diagnosed with otitis externa. Which of the following should the nurse teach the patient before the patient leaves the clinic?
a)
Side effects of oral antibiotics
b)
Strategies to cope with the temporary sensorineural hearing loss
c)
Proper instillation of prescribed ear drops
d)
Cleaning ear canal with cotton-tip applicator after showering
c)
Proper instillation of prescribed ear drops
Explanation:
Otitis externa is usually treated with antimicrobial otic drops. The nurse should anticipate teaching the patient how to instill the ear drops properly. Otitis externa is usually not treated with oral antibiotics because it is not a systemic issue. A cotton-tip applicator should not be used in the ear canal because it can cause trauma, which may lead to otitis externa. Otitis externa may have temporary conductive hearing loss, not a sensorineural one.
A patient is newly diagnosed with benign paroxysmal positional vertigo. Which of the following is the highest priority nursing intervention?
a)
Teach balance exercises.
b)
Administer meclizine for 1 to 2 weeks.
c)
Encourage bed rest.
d)
Attempt the Epley/canalith repositioning procedure.
c)
Encourage bed rest.
Explanation:
Bed rest is recommended for patients with acute symptoms. Best rest can ease the symptoms while keeping the patient safe. Epley/canalith repositioning procedures (CRP) may be used to provide resolution of vertigo. The patient is usually vomiting and may need to be medicated with an antiemetic before the procedure can be tried. Patients with acute vertigo may be medicated with meclizine for 1 to 2 weeks, but since safety is a concern bed rest would be the highest priority. Balance exercises would not be taught until the acute symptoms have eased. These exercises will help the brain compensate for the vestibular disorder.
hich of the following is a definition of ossiculoplasty?
a)
Surgical repair of the eardrums
b)
Incision into the eardrum
c)
Incision into the tympanic membrane
d)
Surgical reconstruction of the middle ear bones
d)
Surgical reconstruction of the middle ear bones
Explanation:
Ossiculoplasty is performed to restore hearing. Surgical repair of the eardrum is termed tympanoplasty. Tympanotomy or myringotomy is the term used to refer to incision into the tympanic membrane.
A patient undergoing mastoid surgery asks the nurse about the pain following the surgery. Which of the following responses by the nurse is appropriate?
a)
“The incisional pain usually last 3 weeks. The doctor will make sure you have enough pain medications.”
b)
“Most patients report a sharp shooting pain for 1 to 2 months following the surgery from the Eustachian tube opening.”
c)
“Usually there is a constant throbbing pain for the first week. Most patients report no pain with the use of the pain medications.”
d)
“Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours.”
d)
“Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours.”
Explanation:
The incisional pain from mastoid surgery is usually mild and controlled by prescribed pain medications. The patient should be taking medications routinely the first 24 hours and, as needed, after 24 hours. Incisional pain usually does not last 3 weeks. The patient may feel a sharp shooting pain when the Eustachian tube is open for 2 to 3 weeks following surgery. A constant throbbing pain may indicate an infection and should be investigated.
Psychococial- self concept, spiritual helth, culutre, sexuality
Evolve Questions
A 6-month-old child from Guatemala was adopted by an American family in Indiana. The child’s socialization into the American midwestern culture is best described as:
Assimilation
.
Acculturation
.
Biculturalism.
Enculturation.
Enculturation
Socialization into one’s primary culture as a child is known as enculturation.
A 46-year-old woman from Bosnia came to the United States 6 years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of the United States because she:
Chose to be bicultural.
Adapted to and adopted the American culture.
Had an extremely negative experience with the American culture.
Gave up part of her ethnic identity in favor of the American culture.
Adapted to and adopted the American culture.
Assimilation results when an individual gradually adopts and incorporates the characteristics of the dominant culture.
To enhance their cultural awareness, nursing students need to make an in-depth self-examination of their own:
Motivation and commitment to caring.
Social, cultural, and biophysical factors.
Engagement in cross-cultural interactions.
Background, recognizing her biases and prejudices.
Background, recognizing her biases and prejudices
Cultural awareness is an in-depth self-examination of one’s own background, recognizing biases and prejudices and assumptions about other people.
Which of the following is required in the delivery of culturally congruent care?
Learning about vast cultures
Motivation and commitment to caring
Influencing treatment and care of patients
Acquiring specific knowledge, skills, and attitudes
Acquiring specific knowledge, skills, and attitudes
Specific knowledge, skills, and attitudes are required in the delivery of culturally congruent care.
A registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient?
“What are your dietary preferences?”
“What time do you typically go to bed?”
“Do you bathe and use deodorant more than one time a week?”
“Do you have any health issues that we should know about?”
Do you bathe and use deodorant more than one time a week?
Nurses need to avoid stereotypes or unwarranted generalizations about any particular group that prevents further assessment of the individual’s unique characteristics.
When action is taken on one’s prejudices:
Discrimination occurs.
Delivery of culturally congruent care is ensured.
Effective intercultural communication develops.
Sufficient comparative knowledge of diverse groups is obtained.
Discrimination occurs
Prejudices associate negative permanent characteristics with people who are different from the valued group. When a person acts on these prejudices, discrimination occurs.
A nursing student is doing a community health rotation in an inner-city public health department. The student investigates sociodemographic and health data of the people served by the health department, and detects disparities in health outcomes between the rich and poor. This is an example of a(n):
Illness attributed to natural and biological forces.
Creation of the student’s interpretation and descriptions of the data
.
Influence of socioeconomic factors in morbidity and mortality.
Combination of naturalistic, religious, and supernatural modalities.
Influence of socioeconomic factors in morbidity and mortality.
Health disparity populations are populations that have a significant increased incidence or prevalence of disease or that have increased morbidity, mortality, or survival rates compared to the health status of the general population.
Culture strongly influences pain expression and need for pain medication. However, cultural pain is:
Not expressed verbally or physically.
Expressed only to others from a similar culture.
Usually more intense than physical pain.
Suffered by a patient whose valued way of life is disregarded by practitioners.
Suffered by a patient whose valued way of life is disregarded by practitioners.
Patients suffer cultural pain when health care providers disregard values or cultural beliefs.
Which of the following best represents the dominant values in American society on individual autonomy and self-determination?
Physician orders
Advance directive
Durable power of attorney
Court-appointed guardian
Advance directive
Informed consent and advance directives protect the right of the individual to know and make decisions ensuring continuity of individual autonomy and self-determination.
The nurse at an outpatient clinic asks a patient who is Chinese American with newly diagnosed hypertension if he is limiting his sodium intake as directed. The patient does not make eye contact with the nurse but nods his head. What should the nurse do next?
Ask the patient how much salt he is consuming each day
Discuss the health implications of sodium and hypertension
Remind the patient that many foods such as soy sauce contain “hidden” sodium
Suggest some low-sodium dietary alternatives
Ask the patient how much salt he is consuming each day
In an Asian culture spoken messages often have little to do with their meanings. It is important for the nurse to clarify how much salt the patient is consuming in his diet.
A female Jamaican immigrant has been late to her last two clinic visits, which in turn had to be rescheduled. The best action that the nurse could take to prevent the patient from being late to her next appointment is:
Give her a copy of the city bus schedule.
Call her the day before her appointment as a reminder to be on time.
Explore what has prevented her from being at the clinic in time for her appointment.
Refer her to a clinic that is closer to her home.
Explore what has prevented her from being at the clinic in time for her appointment.
Present-time orientation is in conflict with the dominant organizational norm in health care that emphasizes punctuality and adherence to appointments. Nurses need to expect conflicts and make adjustments when caring for ethnic groups.
A nursing student is taking postoperative vital signs in the postanesthesia care unit. She knows that some ethnic groups are more prone to genetic disorders. Which of the following patients is most at risk for developing malignant hypertension?
Ashkenazi
Jew
Chinese
American
African American
Filipino
African American
A community health nurse is making a healthy baby visit to a new mother who recently emigrated to the United States from Ghana. When discussing contraceptives with the new mom, the mother states that she won’t have to worry about getting pregnant for the time being. The nurse understands that the mom most likely made this statement because:
She won’t resume sexual relations until her baby is weaned.
She is taking the medroxyprogesterone (Depo-Provera) shot.
Her husband was recently deployed to Afghanistan.
She has access to free condoms from the clinic.
She won’t resume sexual relations until her baby is weaned
In some African cultures such as in Ghana and Sierra Leone some women will not resume sexual relations with their husbands until the baby is weaned.
During their clinical post-conference meeting, several nursing students were discussing their patients with their instructor. One student from a middle-class family shared that her patient was homeless. This is an example of caring for a patient from a different:
Ethnicity.
Culture.
Heritage.
Religion.
Culture
Culture is the context in which groups of people interpret and define their experiences relevant to life transitions. This includes events such as birth, illness, and dying. It is the system of meanings by which people make sense of their experiences.
When interviewing a Native American patient on admission to the hospital emergency department, which questions are appropriate for the nurse to ask? (Select all that apply.)
Do you use any folk remedies?
Do you have a family physician?
Do you use a Shaman?
Does your family have a history of alcohol abuse?
Do you use any folk remedies?
Do you have a family physician?
Do you use a Shaman?
Obtain information about folk remedies and cultural healers that the patient uses. Assessment data yield information about the patient’s beliefs about the illness and the meaning of the signs and symptoms
Following a bilateral mastectomy, a 50-year-old patient refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which of the following is the best response from the nurse?
“What’s the special occasion?”
“You must be feeling better today.”
“This is the first time I have seen you look this good.”
“I see that you’ve combed your hair and put on makeup.”
“I see that you’ve combed your hair and put on makeup.”
When the nurse uses a matter-of-fact approach and acknowledges a change in the patient’s behavior or appearance, it allows the patient to establish its meaning.
A patient diagnosed with major depressive disorder has a nursing diagnosis of chronic low self-esteem related to negative view of self. Which of the following would be the most appropriate cognitive intervention by the nurse?
Promote active socialization with other patients
Role play to increase assertiveness skills
Focus on identifying strengths and accomplishments
Encourage journaling of underlying feelings
Focus on identifying strengths and accomplishments
Focusing on strengths and accomplishments to minimize the emphasis on failures assists the patient to alter distorted and negative thinking. The other interventions are important, but they are not designed to impact thoughts.
Several staff members complain about a patient’s constant questions such as “Should I have a cup of coffee or a cup of tea?” and “Should I take a shower now or wait until later?” Which interpretation of the patient’s behavior helps the nurses provide optimal care?
Asking questions is attention-seeking behavior.
Inability to make decisions reflects a self-concept issue.
Dependence on staff must be stopped immediately.
Indecisiveness is aimed at testing how the staff reacts.
Inability to make decisions reflects a self-concept issue.
Patients with deficits in self-concept often have difficulty making decisions. It is essential for the nurse to remain accepting of the patient and to support him or her in decision making.
A depressed patient is crying and verbalizes feelings of low self-esteem and self-worth such as “I’m such a failure…I can’t do anything right.” The best nursing response would be to:
Remain with the patient until he or she stops crying.
Tell the patient that is not true and that every person has a purpose in life.
Review recent behaviors or accomplishments that demonstrate skill ability.
Reassure the patient that you know how he is feeling and that things will get better.
Remain with the patient until he or she stops crying.
Demonstrating acceptance of the patient by supportively sitting with him or her builds a therapeutic nurse-patient relationship. The nurse’s presence signals value and allows the patient to explore issues of self-concept and self-esteem.
