Final Flashcards
1) What are the two components of the sensory process? A) Stimulus and receptor B) Kinesthesia and stereognosis C) Visual and auditory D) Reception and perception
Answer: D
Explanation: A) The sensory process involves two components: reception and perception. Sensory reception is the process of receiving stimuli or data. Sensory perception involves the conscious organization and translation of the data or stimuli into meaningful information. Stimuli and receptors are aspects of how sensory information is received and perceived. Kinesthesia is awareness of the position and movement of body parts, and stereognosis is the ability to perceive and understand an object through touch. Visual and auditory stimuli are parts of how the body senses the external world.
2) The nurse is selecting sensory aids for a client with deficits in hearing and sight. Which aid would address both sensory deficits?
A) Adequate room lighting with night lights
B) Flashing alarm clock with large numbers
C) Amplified telephone
D) Large-print reading material
Answer: B
Explanation: A) A flashing alarm clock would be helpful for a client with a hearing deficit, and a clock with large numbers would be helpful for a client with a sight deficit. Adequate room lighting with night lights and large-print reading material help with a sight deficit but not a hearing deficit, and an amplified telephone helps with a hearing deficit but not a sight deficit.
3) The nurse is planning care for an older adult client diagnosed with age-related macular degeneration (AMD) that is nonexudative. Which therapies should the nurse anticipate for this client? Select all that apply. A) Laser surgery B) Eye patches C) Antioxidants D) Eyedrops E) Zinc
Answer: C, E
Explanation: A) High-dose antioxidants and zinc are the treatments of choice for early-to-intermediate dry AMD. Laser surgery is used to treat wet macular degeneration. Eyedrops and eye patches may be used after laser surgery but are not part of the initial treatment for the disorder.
4) A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. Which tool should the nurse select to assess this client? A) Rosenbaum eye chart B) Penlight C) Cover-uncover test D) Snellen eye chart
Answer: A
Explanation: A) The Rosenbaum eye chart is used to test for near or reading vision. The Snellen chart is used to test far or distant vision. A penlight is used to test extraocular movements and pupillary response. The cover-uncover test is used to assess for eye muscle strength.
5) Which diagnostic test should the nurse use to assess hearing in an infant? A) Otoacoustic emissions test B) Weber test C) Rinne test D) Whisper test
Answer: A
Explanation: A) The otoacoustic emissions test uses an earphone and microphone to play sounds into the ear. Failure to detect an echo indicates hearing loss. This test is almost exclusively performed on infants as part of the routine hearing screening. The Rinne and Weber tests assess bone and air conduction with the use of a tuning fork. The whisper test provides a rough estimate of hearing loss. All three of these other tests involve active participation from the client.
6) The nurse is providing teaching on the recommended hearing tests for older adults. Which information should be included in this teaching?
A) Schedule an annual hearing test until the age of 50 and then have a test every 6 months.
B) Annual screenings are recommended for adults with diabetes.
C) For individuals without comorbidities, hearing exams should be repeated every 1-3 years for ages 55-64, and every 1-2 years for ages 65 and above.
D) Have a hearing test every 10 years until age 50 and then every 3 years.
Answer: D
Explanation: A) Adults should be screened for hearing at least every 10 years until the age of 50 and then every 3 years. A biannual or annual hearing test is not necessary for this age group. Annual screenings for vision are recommended for adults with diabetes, and for individuals without comorbidities, eye exams should be repeated every 1-3 years for ages 55-64, and every 1- years for ages 65 and above.
7) The nurse is conducting a prenatal assessment on a client. Which finding indicates a risk of sensory impairment in the unborn child? A) Lack of immunity to rubella B) History of otitis media C) Immunity to varicella D) Brief case of moderate conjunctivitis
Explanation: A) Maternal infection with rubella during pregnancy can cause vision impairment in newborns. Thus, lack of immunity to rubella indicates an increased risk of sensory impairment in the newborn. Immunity to varicella is a desirable trait that reduces a mother’s chance of illness during pregnancy, thus lessening the likelihood of harm to the newborn. Sensory deficits resulting from maternal otitis media would not be hereditary. Conjunctivitis, or pink eye, is an infection that usually clears up on its own and is not congenital.
8) A client is experiencing visual overstimulation. What can the nurse do immediately to reduce this client’s visual sensory overload?
A) Suggest the client wear sunglasses that block UVA rays only.
B) Reduce the amount of light in the room by lowering shades and turning off overhead lights.
C) Provide the client with large-print reading materials.
D) Encourage the patient to employ relaxation techniques to reduce anxiety and stress.
Answer: B
Explanation: A) For clients who are at risk of overstimulation, nurses should assist with reducing the number and types of environmental stimuli. Appropriate measures for addressing visual overstimulation include lowering the shades and turning off overhead lights. Dark glasses that block both UVA and UVB rays are also useful. Relaxation techniques would be good for the client to employ but would require teaching for the client to properly implement them. Large-print reading materials would be helpful for a client with visual impairment but not a client who is experiencing visual sensory overload.
9) A nurse is caring for a client with a genetic nerve disorder who has difficulty when attempting to move her tongue. The nurse recognizes that this may indicate a deficit in the functioning of which cranial nerve? A) XII B) XI C) VIII D) VI
Answer: A
Explanation: A) The movement of the tongue for speech and swallowing is controlled by cranial nerve (CN) XII, hypoglossal. XI CN (accessory) controls the movement of head and neck as well as proprioception. CN VIII (acoustic/vestibulocochlear) controls hearing and the sense of balance. CN VI (abducens) control eyeball movement and moves eye laterally.
10) Which nursing action is most appropriate when communicating with a client who has a hearing deficit?
A) Drawing out the articulation of words with extra emphasis in order for the client to understand
B) Using shorter phrases, which tend to be easier to understand than longer ones
C) Varying the volume of voice, which is easier to understand than one consistent volume
D) Writing ideas or pantomiming as appropriate in order for the client to understand
Answer: D
Explanation: A) Writing ideas and pantomiming as appropriate are acceptable forms of communication for a client who has a hearing deficit. The nurse should not overarticulate words, use short phrases, or vary the volume of voice because these things make it more difficult to understand for the client with a hearing deficit.
11) What is vertigo? A) Involuntary rapid eye movements B) A feeling of rotation or imbalance C) An infection of the vestibular nerve D) Impaired olfaction
Answer: B
Explanation: A) Vertigo is a feeling of rotation or imbalance. Nystagmus is involuntary rapid eye movements. Vestibular neuritis is an infection of the vestibular nerve that is a common cause of vertigo. Impaired olfaction, or impaired sense of smell, has nothing to do with vertigo
12) Where does perception, or the awareness and interpretation of stimuli, take place? A) The brain B) The nerve receptors C) The peripheral nervous system D) The impulses
Answer: A
Explanation: A) Perception, or awareness and interpretation of stimuli, takes place in the brain. The nerve receptors convert stimuli to impulses that travel along nerve pathways to the spinal cord or directly to the brain.
13) What characterizes individuals with achromatopsia?
A) They perceive only the secondary colors of purple, orange, and green.
B) They perceive only the primary colors of red, blue, and yellow.
C) They perceive some colors as indistinguishable from other colors.
D) They perceive only shades of gray and no colors.
Answer: D
Explanation: A) Achromatopsia is a rare form of color blindness in which the individual cannot distinguish any color at all and sees only shades of gray. The most common variant of color blindness is the inability to distinguish between red and green. Less common is the inability to distinguish between blue and yellow. Many people with the blue-yellow variant also have problems distinguishing between green and red.
The nurse suspects that an older adult client has a hearing disorder; however, the client denies not being able to hear, and the family thinks the client is just becoming more absent minded with age. Which initial action by the nurse to assess the client’s hearing is appropriate?
A) Use an otoscope to visualize the inner ear.
B) Schedule a Weber and Rinne test.
C) Confront the client with the suspicion.
D) Observe the client’s interaction with family
Answer: D
Explanation: A) The most telling of these options would be to observe the client’s interactions with family. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip reading. The Weber and Rinne test and use of an otoscope may be a part of an assessment but will not yield the immediate information that simple observation would. The client has already denied having a hearing problem, so confronting the client with the nurse’s suspicion will probably only alienate the client from the nurse.
A nurse is providing teaching to a young adult client who is occasionally exposed to loud explosions on the job site. Which statement on the part of the client indicates that he accurately understands the potential risk to his hearing?
A) “If my hearing is damaged on the job, I can have surgery to fix it.”
B) “Hearing loss from exposure to loud noises actually has a genetic component.”
C) “Damage to the ear from loud noises can cause permanent hearing loss.”
D) “Hearing loss attributed to loud noises is normally reversible, especially in younger people.”
Answer: C
Explanation: A) Hearing loss attributed to loud noises can be profound and is often permanent, regardless of a person’s age. With sensorineural hearing loss, the only hope for restoring sound perception might be a cochlear implant; however, this surgery is not appropriate for all cases of sensorineural hearing loss, and even if a client is an ideal candidate, implants aren’t always successful. Hearing loss from loud noises has no genetic component.
) Which is the decibel level for mild hearing loss? A) 16-40 dB B) 41-70 dB C) 71-90 dB D) 91+ dB
Answer: A
Explanation: A) Hearing loss is expressed in terms of decibels, or units of loudness. 41-70 dB is moderate hearing loss, at which most normal conversational sounds are missed. 16-40 dB is mild hearing loss, at which some speech sounds are difficult to perceive. 71-90 dB is severe hearing loss, at which speech sounds cannot be heard at a normal conversational level. 91+ dB is profound hearing loss and constitutes legal deafness.
The nurse is identifying nursing diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be the lowest priority for this client? A) Impaired Verbal Communication B) Social Isolation C) Nausea D) Risk for Injury
Answer: C
Explanation: A) Possible nursing diagnoses for the patient with hearing impairment may include Impaired Verbal Communication, Social Isolation, and Risk for Injury. Nausea is accurate for a client who has tinnitus, vertigo, and nausea; however, the greater priorities for this client would be safety related to falls, ensuring effective communication, and ensuring that the client does not become socially isolated.
Which client should the nurse identify as having the greatest risk for hearing loss?
A) Construction worker who typically works in urban centers
B) Adolescent who occasionally listens to loud music on headphones
C) Teacher who works at a large high school
D) Lawyer who enjoys snowmobiling once a year
Answer: A
Explanation: A) The construction worker is likely to have the greatest risk for hearing loss because the client’s occupation and typical work environment probably involve sustained exposure to very loud noises. An adolescent who occasionally listens to loud music on headphones is also at risk for hearing loss, but the exposure to loud sounds is only occasional. The teacher working at a large high school works in a noisy environment but is probably not typically exposed to sounds louder than the human voice. Snowmobiles can be loud enough to present a risk for hearing loss, but the lawyer’s exposure to them is only once a year.
A nurse is evaluating the care received by a client who has a hearing deficit. Which statement indicates that the client is effectively addressing variables that may lead to social isolation?
A) “I ask others to face me when they talk because I can hear them better.”
B) “I keep the television volume raised to a high level.”
C) “I don’t use my hearing aid unless someone seems to need to talk to me.”
D) “I might use the hearing aid when I go shopping.”
Answer: A
Explanation: A) Evidence that the client is effectively addressing variables that may lead to social isolation would include the client’s account of asking others to face him or her when talking. This indicates that the client is taking an active role in improving communication with others. Clients should be encouraged to interact with friends and family on a one-to-one basis in quiet settings. Listening to a loud television at all times is not conducive to good communication. The other responses indicate a reluctance to use an assistive device unless necessary, which does not generally encourage social interaction.
Which strategy for communication enhancement incorporates the use of shapes? A) Sign language B) Oral approach C) Total communication D) Cued speech
Answer: d
Explanation: A) Of the strategies listed, only cued speech incorporates the use of shapes. Specifically, cued speech accompanies oral speech with hand shapes that represent groups of consonant sounds. Both sign language and total communication use signs, not shapes. An oral approach involves only spoken communication and avoids the use of formal signs.
) A school nurse is identifying students who may have hearing loss. Which student would the nurse be most concerned about?
A) A child who startles easily at loud noises
B) A child who gets annoyed when things like televisions are too loud
C) A child who cannot follow conversations in the hallways between classes or in the cafeteria
D) A child who likes to listen to music on earbuds
Answer: C
Explanation: A) The child who cannot follow conversations in the hallways between classes or in the cafeteria appears to be having trouble understanding speech when background noise is present, which is a sign that the child may require further evaluation for hearing loss. A child not startling at loud noises would be a sign of hearing loss. A child who gets annoyed when electronic devices are too loud or who likes to listen to music on earbuds is behaving normally
A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. Which of the following should the nurse plan on teaching the client how to do?
A) Understand the actions and drug interactions of aminoglycosides.
B) Self-monitor for hearing loss.
C) Use total communication.
D) Understand cued speech.
Answer: B Explanation: A) Tobramycin, an aminoglycoside antibiotic, is used in the treatment of advanced bacterial infections and for the treatment of tuberculosis. A potential serious adverse effect of this class of medication is ototoxicity, affecting the client's hearing. The nurse should plan on teaching the client how to self-monitor for hearing loss. Total communication and cued speech are approaches to enhancing communication with clients who have a hearing deficit. It is not important for the client to understand the actions and drug interactions of the group of drugs to which tobramycin belongs.
A nurse is working with several clients who are experiencing hearing loss. Of these clients, which is the best candidate for a cochlear implant?
A) A client with a perforated tympanic membrane
B) A client with sensorineural hearing loss from long-term exposure to loud noise
C) A client with an obstruction of the external ear canal
D) A client with a tumor of the middle ear
Answer: B
Explanation: A) For the client with a sensorineural hearing loss, a cochlear implant may be the only hope for restoring sound perception. Clients with a perforated tympanic membrane, an obstruction of the external ear canal, or a tumor of the middle ear all have problems that lead to conductive hearing loss, which would not be treated with a cochlear implant.
What is characteristic of conductive hearing loss?
A) For loss of hearing to be the same at all frequencies
B) For loss of hearing to primarily involve the upper frequencies
C) For loss of hearing to primarily involve the middle frequencies
D) For loss of hearing to primarily involve the lower frequencies
Answer: A
Explanation: A) Conductive hearing loss involves an equal loss of hearing at all frequencies. If the level of sound is greater than the threshold for hearing, speech discrimination is good. Because of this, the patient with a conductive hearing loss benefits from amplification by a hearing aid. Sensorineural hearing loss typically affects the ability to hear high-frequency tones
What is conductive hearing loss?
A) Degeneration of the hair cells of the cochlea
B) Damage to the hair cells of the organ of Corti
C) Disruption of the transmission of sound from the external auditory meatus to the inner ear
D) Decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli
Answer: C
Explanation: A) Conductive hearing loss is any disruption of the transmission of sound from the external auditory meatus to the inner ear. Sensorineural hearing loss is a decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli. Damage to the hair cells of the organ of Corti is a significant cause of sensorineural hearing deficit. Degeneration of the hair cells of the cochlea is involved in progressive sensorineural hearing loss with aging, called presbycusis.
Which of the following best describes tinnitus?
A) A ringing sound accompanying perception of high-frequency tones
B) Auditory perception from visual stimuli
C) Lack of auditory perception of external auditory stimuli
D) Auditory perception without external auditory stimuli
Answer: D
Explanation: A) Tinnitus is the perception of sound or noise in the ears without stimulus from the environment. The sound may be steady, intermittent, or pulsatile and is often described as a buzzing, roaring, or ringing. It would not be ringing accompanying the perception of high-frequency tones because such a perception would involve external auditory stimuli. Lack of auditory perception of external auditory stimuli is lack of hearing. Tinnitus does not involve perception of visual stimuli as auditory.
After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. Which response by the nurse is accurate?
A) “Only your doctor can tell if you have a cataract in your left eye.”
B) “Cataracts develop at different rates, so one eye may be more affected than the other.”
C) “The changes being confined to one eye indicate a less severe cataract.”
D) “Surgery is still necessary for both eyes.”
Answer: B
Explanation: A) The nurse should respond that cataracts tend to occur in both eyes and develop at different rates, and one cataract generally matures more rapidly than the other. The nurse should not tell the client that the healthcare provider is the only one who can tell if the client has a cataract in the left eye. The lack of vision changes in the left eye does not necessarily indicate the severity of the condition, and surgery might not be necessary for either eye.
Which assessment finding supports the nurse's conclusion that a client is at risk for cataracts? A) Age 75 years B) Hypertension C) Moderate alcohol use D) Smoker
Answer: A
Explanation: A) Age is the greatest single risk factor for cataracts. Environmental and lifestyle factors, such as long-term exposure to sunlight, increase the risk for cataracts; cigarette smoking and heavy alcohol consumption are associated with earlier cataract development. This client’s age would indicate a predisposition for cataract formation, but not hypertension or only moderate alcohol use. Being a smoker would indicate such a predisposition, but this is still not as great a risk factor as the client’s age.
) A nurse is caring for several pediatric clients who are affected by cataracts. Of these clients, which is the most obvious candidate for surgical removal of the cataract?
A) Two-month-old infant who is asymptomatic
B) Six-month-old infant with difficulty noticing toys or faces
C) Three-month-old infant with diminished reaction to bright light
D) One-month-old infant with no reaction to bright light and failure to notice toys or faces
Answer: D
Explanation: A) If vision impairment is significant, the infant should undergo surgical removal of the cataract within the first 2 months of life. For children older than 2 months, cataract surgery should be performed at the discretion of the healthcare provider. The asymptomatic 2-month-old infant is not displaying signs of significant vision impairment, but the 1-month-old infant is.
An older adult client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which is the priority nursing diagnosis for this client?
A) Disturbed Body Image
B) Decisional Conflict: Cataract removal
C) Risk for Ineffective Health Maintenance
D) Ineffective Coping
Answer: C
Explanation: A) The client has arthritis, which is a chronic condition and may interfere with the client’s ability to manage self-care and postoperative care after cataract removal. Risk for Ineffective Health Maintenance is the diagnosis with the highest priority for the client at this time. There is no evidence to suggest the client is not coping or is experiencing decisional conflict regarding the removal of the cataracts. The client might have a disturbed body image; however, postoperative care is the highest priority at this time.
The nurse is planning care for a client scheduled for cataract surgery. Which intervention should the nurse include in the plan of care to help provide a safe environment for the client following surgery?
A) Ensuring fall hazards are removed from the client’s home and additional lighting is provided
B) Educating the client about what self-care activities are necessary following surgery
C) Making the client’s close family aware of the self-care instructions the client has received
D) Ensuring the client’s employer does not expect the client to return to standard duties until clearance for such activities by the healthcare provider
Answer: A
Explanation: A) The removal of fall hazards from the client’s home and provision of additional lighting best demonstrates providing a safe environment for the client following surgery. It’s important for the client to understand what self-care activities are necessary, and it’s good that the client’s close family members are aware of the self-care instructions the client has received and that the client’s employer doesn’t expect an immediate return to standard duties, but these don’t relate directly to providing a safe environment
Which diagnostic technique is used to confirm the location and extent of cataracts?
A) Visually inspecting the optic fundus using an ophthalmoscope
B) Using tonometry to indirectly measure intraocular pressure
C) Revealing a dark area instead of the red reflex through ophthalmoscopy
D) Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract
Answer: D
Explanation: A) Cataracts are diagnosed on the basis of the patient’s history and eye examination. The Snellen and Rosenbaum charts are used. A dilated eye exam with either an ophthalmoscope or slit-lamp examination provides a magnified view of the structures of the eye. Ophthalmoscope examination confirms the diagnosis by identifying the location and extent of a cataract. Revealing a dark area is something that would happen only as the cataract matures. Visually inspecting the optic fundus and using tonometry to measure intraocular pressure are diagnostic tests for glaucoma.
A client has been diagnosed with cataracts of both eyes. The client’s vision and activities of daily living have become severely impaired. What collaborative intervention does the nurse anticipate for this client?
A) Corrective lenses for the cataracts
B) Two surgical procedures, separated by a few weeks, to remove the cataracts
C) Two surgical procedures to remove both cataracts at the same time
D) Eyedrops to treat the cataracts
Answer: B
Explanation: A) Surgery is the only treatment for cataracts. The client will have one cataract removed, and then, in a few weeks, the other cataract will be removed. Cataracts cannot be treated with eyedrops or corrective lenses.
A client is undergoing surgery to manage glaucoma. When providing postoperative teaching to this client, the nurse should emphasize that the client is now at increased risk for which form of cataracts? A) Congenital B) Secondary C) Radiation D) Traumatic
Answer: B
Explanation: A) A secondary cataract may form following surgery to correct another eye disorder. Congenital cataracts are hereditary and appear at birth or in early childhood. Traumatic cataracts result from injury to the eye, and radiation cataracts result from long-term exposure to radiation.
Which of the following diagrams would the nurse use when describing open-angle glaucoma to a client?
A) A diagram showing a completely closed anterior chamber angle
B) A diagram showing a completely occluded outflow of aqueous humor
C) A diagram showing a blockage of the trabecular meshwork and canal of Schlemm
D) A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm
Answer: D
Explanation: A) The diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm demonstrates open-angle glaucoma. In open-angle glaucoma, the anterior chamber angle would be normal but outflow of aqueous humor would be reduced, although not to the degree that it was completely prevented, causing a rising intraocular pressure.
Which assessment finding is consistent with a diagnosis of open-angle glaucoma?
A) A client loses vision intermittently several times over the course of several hours.
B) A client has an episode of lost vision when experiencing a panic attack.
C) A client loses the ability to see at all during a city-wide blackout.
D) A client experiences gradually diminishing vision in both eyes over an extended period.
Answer: D
Explanation: A) Open-angle glaucoma tends to be a chronic and gradually progressive disease. It typically affects both eyes, although the pressures and progression may not be symmetric. Patients with angle-closure glaucoma may have intermittent episodes lasting several hours before they have a more typical prolonged attack of angle-closure glaucoma. Because of the effect of pupil dilation on aqueous outflow in angle-closure glaucoma, episodes often occur in association with darkness, emotional upset, or other factors that cause the pupil to dilate.
An older adult client is using prescription eyedrops to treat her glaucoma. When providing client teaching about this medication, which of the following should the nurse mention as potential side effects? Select all that apply. A) Blurred vision B) Intermittent loss of eyesight C) Headaches D) Clouding of the eyes E) Change in eye color
Answer: A, E
Explanation: A) The client is taking a prostaglandin analog as eyedrops, which can cause the side effect of a change in iris color. Other potential side effects are blurred vision, eye pain (itching, burning, stinging), and eye redness, but not intermittent eyesight loss, headaches, or clouding of the eyes.
The nurse is planning care for a client with glaucoma who is experiencing anxiety as a result of the diagnosis. Which intervention should the nurse select to address this need?
A) Assure the client there is nothing to be afraid of.
B) Support the client’s use of coping mechanisms.
C) Turn off the lights when leaving the client’s room.
D) Refer the client to a counseling psychologist.
Answer: B
Explanation: A) Anxiety is a common response to a new diagnosis of glaucoma. Here, the most appropriate intervention would be for the nurse to support the client’s use of coping mechanisms. Although referral to a psychologist may be necessary at some point, it typically is not an initial course of action. Assuring the client there is nothing to be afraid of minimizes the client’s concerns and is not appropriate. Turning off the lights is not an intervention that will lessen the client’s anxiety.
The nurse is evaluating instructions provided to a client with glaucoma. Which client statement indicates that teaching has been effective?
A) “The eyedrops only need to be used when my eyes hurt.”
B) “I can stop the eyedrops when the glaucoma has resolved.”
C) “I must use my eyedrops as prescribed for the rest of my life.”
D) “I will need to continually increase the dose of my eyedrops.”
Answer: C
Explanation: A) Glaucoma can be controlled but not cured; the client must use eyedrops for the rest of his life. Eyedrops must be used continuously as prescribed; most clients with glaucoma do not experience eye pain. Increasing the dosage of eyedrops is only necessary if the ocular pressure is not controlled; this must be determined by the healthcare provider, not the client.
The nurse is caring for a client who has been using timolol (Timoptic) to manage glaucoma. Which assessment finding supports an adverse effect associated with systemic absorption of the drug? A) Eye pain B) Heart rate of 57 C) Urinary frequency D) Blurred vision
Answer: B
Explanation: A) The onset of bradycardia must be evaluated. Timoptic is a beta-adrenergic blocker. It is associated with bradycardia in some clients. Frequent urination is associated with the use of carbonic anhydrase inhibitors. Eye pain and dim or blurred vision are associated with the use of miotic medications.
The nurse is planning instruction for a client who is newly diagnosed with glaucoma. What should be included in this teaching? Select all that apply.
A) Manage eye pain with over-the-counter analgesics.
B) Clouding of the affected eye(s) is expected.
C) Self-administer prescribed eye medication properly.
D) Attend follow-up appointments with the physician.
E) Avoid over-the-counter medication unless discussed with the physician.
Answer: C, D, E
Explanation: A) When instructing a client on how to manage the diagnosis of glaucoma, the nurse should include why the client needs to avoid over-the-counter medication unless discussed with the physician, the method to self-administer prescribed eye medication, and the importance of attending follow-up appointments with the physician. Eye pain or clouding of affected eyes is not to be expected and should be reported to the physician.
Which of the following scenarios is consistent with secondary congenital glaucoma?
A) A newborn is diagnosed with glaucoma at birth.
B) An infant is diagnosed at 6 months with glaucoma.
C) A 1-year-old infant develops glaucoma following neurofibromatosis.
D) A 5-year-old child is diagnosed with glaucoma
Answer: C
Explanation: A) Secondary congenital glaucoma results from disorders of the eye or the body, including Sturge-Weber syndrome, Axenfeld-Rieger syndrome, aniridia, and neurofibromatosis, so the 1-year-old infant who develops glaucoma following neurofibromatosis has secondary congenital glaucoma. The newborn diagnosed at birth with glaucoma has congenital glaucoma, the infant diagnosed at 6 months has infantile glaucoma, and the child diagnosed at 5 years has juvenile glaucoma.
A nurse is caring for a client with glaucoma who is prescribed an ophthalmic beta-adrenergic blocking agent. When teaching the client about the therapeutic action of this medication, which of the following statements should the nurse include?
A) “This drug reduces pressure in the eye by relaxing the muscles of the eye.”
B) “This medication only needs to be taken when eye pain is experienced.”
C) “Systemic absorption may occur, resulting in hypotension, bradycardia, and shortness of breath.”
D) “This drug reduces intraocular pressure by decreasing the production of fluid in the
Answer: D Explanation: A) Ophthalmic beta-adrenergic blocking agents are one type of pharmacologic therapy used in the treatment of glaucoma. This class of medication works to reduce intraocular pressure by decreasing the production of aqueous humor in the ciliary body. Systemic absorption is a potential side effect of this type of drug, not the therapeutic action of the drug. This type of drug should be taken once or twice a day, not on as-needed basis when pain occurs. Relaxation of the ciliary muscle is an effect of prostaglandin analog drugs, another class of medications used in the treatment of glaucoma.
An older adult client tells the nurse that reading is easier when the material is held to the left or right. What should the nurse suspect this client is experiencing? A) Cataract B) Detached retina C) Exudative macular degeneration D) Nonexudative macular degeneration
Answer: D
Explanation: A) Symptoms of age-related macular degeneration usually develop gradually and include needing more light to read, blurriness of print, or a blurred or blind spot in the central vision. The macular degeneration is likely nonexudative (dry) because that is the more common kind and it develops before the exudative (wet) type. Cloudy vision is seen with cataracts. When the retina detaches, the client experiences floaters, or spots, and lines or flashes of light in the visual field.
The nurse is providing teaching to a client related to maintaining healthy vision. Which of the following should the nurse identify as a modifiable risk factor for macular degeneration? A) Caucasian ancestry B) Smoking 1 pack of cigarettes per day C) 62 years of age D) Family history of AMD
Answer: B
Explanation: A) Although aging is the most significant risk factor for the development of macular degeneration, and being Caucasian and having a family history of AMD are also risk factors, of the options listed, only smoking is modifiable, meaning that it is a risk factor the client can control.
An older adult client with intermediate dry macular degeneration calls the nurse complaining that his vision is suddenly much more distorted and colors do not seem right. Which action by the nurse is priority?
A) Talk with the client to assess for other hallucinations that might be occurring.
B) Check the client’s medications for side effects of vision changes.
C) Ensure the client’s safety by raising the bedrails.
D) Contact the healthcare provider for an immediate ophthalmologic evaluation.
Answer: D
Explanation: A) Individuals with dry intermediate macular degeneration can progress to exudative macular degeneration. A sudden distortion in vision and impaired color vision are signs of exudative macular degeneration and require prompt evaluation and treatment. Thus, the nurse needs to contact the healthcare provider so that the client can be seen by an ophthalmologist. The client most likely is not experiencing a side effect of medications. Ensuring the client’s safety is important; however, the nurse needs to do more than raising the bedrails. The client is not hallucinating, although hallucinations are a sign of exudative macular degeneration as well.
Which of the following clients most likely will require assistance with properly taking medications for macular degeneration?
A) 72-year-old client, no dementia, no arthritis, hypertension
B) 67-year-old client, dementia, arthritis, no hypertension
C) 47-year-old client, no comorbidities
D) 52-year-old client, gastroesophageal reflux disease (GERD), hypertension
Answer: B
Explanation: A) Two common conditions in older adults that may affect treatment of macular degeneration are tremors and cognitive decline. Hand tremors may make it difficult for the older adult to adequately apply eyedrops, and cognitive decline may cause older adults to forget to take their medications. Therefore, older adults with these conditions may need a family member or friend who can help them remember to take their medications and potentially apply eyedrops for them. The client with dementia and arthritis, although not the oldest of these clients, has conditions that are most likely to make taking medications properly difficult.
The nurse is preparing discharge instructions for a client with age-related macular degeneration (AMD) and type 1 diabetes mellitus. What should the nurse include in this client’s teaching plan?
A) Information on assisted-living facilities
B) Information on the need to have routine eye examinations every 5 years
C) Referral to home care to ensure safety with administering insulin and AMD medications at home
D) Information on Stargardt disease
Answer: C
Explanation: A) The client has macular degeneration and type 1 diabetes, which means the client needs insulin at least once per day. The nurse should refer the client for home care to ensure that the client can safely provide insulin at home as well as assist with other medications the client might need for management of AMD. The client may or may not need to move to an assisted-living facility. Stargardt disease is the most common type of juvenile macular degeneration and not likely relevant to this client. Routine eye examinations for this client should be done every 2 years.
The nurse is caring for a client in the early stage of macular degeneration. What dietary changes should the nurse recommend to slow the progression of the disease? A) High-antioxidant diet B) Low-antioxidant diet C) Low-fat diet D) High-fat diet
Answer: A
Explanation: A) A diet high in antioxidants–such as fish; green, leafy vegetables; copper; and zinc–has been shown to slow the progression of macular degeneration in its early to intermediate stage when it is nonexudative. Neither low- nor high-fat diets slow the progression of macular degeneration.
A client is receiving verteporfin treatment for macular degeneration. The client asks the nurse what the expected outcome of treatment is. Which response by the nurse is most appropriate?
A) It will increase the effectiveness of surgery.
B) It will reverse the effects on the disease.
C) It will promote the development of new blood vessels.
D) The progression of the disease will be slowed.
Answer: D
Explanation: A) One treatment for macular degeneration is the use of verteporfin, a drug that tends to adhere to the surface of new blood vessels. This medication is injected systemically. Light is then shined into the affected eye, activating the drug and destroying new blood vessels. The best outcome for this treatment is that it will slow the disease. This does not reverse the symptoms of the disease. New vessel growth is not desirable. The client’s condition will be slowed at best; it is not likely to improve. Surgical therapy is rare as a treatment for AMD and this medication does not improve the efficacy of surgery.
The home care nurse is assessing a client with macular degeneration. What interventions would be appropriate to ensure home safety for this client? Seslect all that apply.
A) Keep the stairs free of clutter.
B) Wear socks without shoes when walking in the home.
C) Use one electrical outlet for devices.
D) Have grab bars installed in the bathroom.
E) Remove scatter rugs from the floors in the home.
Answer: A, D, E
Explanation: A) The client with macular degeneration is at risk for injury. To reduce this risk, the nurse should instruct and plan to help the client remove scatter rugs from the floors in the home, have grab bars installed in the bathroom, and keep the stairs free of clutter. The client should not walk without proper footwear. Using one electrical outlet in the home could cause an electrical hazard.
Laser surgery and photodynamic therapy are both treatments for what disease of the eye? A) Congenital cataracts B) Age-related cataracts C) Nonexudative macular degeneration D) Exudative macular degeneration
Answer: D
Explanation: A) Exudative (wet) macular degeneration may be treated by laser surgery or photodynamic therapy. Macular degeneration of the nonexudative (dry) kind is treated with high-dose antioxidants and zinc. Neither laser surgery nor photodynamic therapy is used to treat age-related or congenital cataracts.
What class of drugs both decreases production of aqueous humor in the eye and increases drainage of aqueous humor from the uveoscleral pathway? A) Beta-adrenergic blockers B) Prostaglandin analogs C) Alpha2-adrenergic agonists D) Cholinergic agonists
Answer: C
Explanation: A) Alpha2-adrenergic agonists both decrease production of aqueous humor in the eye and increase drainage of aqueous humor from the uveoscleral pathway. Beta-adrenergic blockers decrease the production of aqueous humor in the eye, but they do not increase drainage of aqueous humor. Prostaglandin analogs increase drainage of aqueous humor from the uveoscleral pathway, but they do not decrease aqueous humor production. Cholinergic agonists increase drainage of aqueous humor through the trabecular meshwork via pupillary constriction.
b Which best describes photophobia? A) Fear of light B) Aversion to light C) Reactive to light D) Need for light
Explanation: A) Photophobia is a sensitivity to light that clients with angle-closure glaucoma may sometimes experience, so aversion to light is closest to describing photophobia. It is not necessarily fear; phobia can be fear or aversion. There are many different types of reactivity to light, but photophobia is specifically a negative reaction. Photophobia typically involves the avoidance of light, not the need for it.
Which statement about cataract surgery is correct?
A) Cataract surgery should be quick but may have to take place in stages.
B) Cataract surgery may only be done on an inpatient basis with general anesthesia.
C) Cataract surgery is not recommended except in cases of opacification of the remaining posterior capsule.
D) Cataract surgery is typically bilateral and can be performed in a single day.
Answer: A
Explanation: A) Cataract surgery should be quick because it typically is done on an outpatient basis with only local anesthesia. If the patient presents with bilateral cataracts, however, surgery is typically performed on only one eye at a time, with an interval of days to several weeks before surgery is performed on the second eye. Cataract surgery is not typically done on an inpatient basis and does not usually involve general anesthesia. Opacification of the remaining posterior capsule is a secondary cataract, which may form following cataract surgery and also should be removed. If a client has bilateral cataracts, the surgery to remove them would typically be performed on different days.
The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal detachment? A) Eye pain and redness B) Floaters in the visual field C) Subconjunctival hemorrhage D) Hyphema
Answer: B
Explanation: A) Of the choices listed, only floaters in the visual field are suggestive of retinal detachment. Eye pain and redness are not associated with retinal detachment. Although subconjunctival hemorrhage and hyphema may occur following a blow to the head, they are unrelated to detachment of the retina.
) A nurse working in the emergency department is caring for a client with an eye injury. The client describes spots in the field of vision. Based on this finding, which of the following is the nurse’s priority concern?
A) The possibility that the client will immediately lose all vision
B) The possibility that the client will experience a progressive deterioration of vision
C) The possibility that the client will begin to experience intense eye pain
D) The possibility that the client’s conjunctiva will become red and edematous
b
Explanation: A) “Floaters,” or irregular lines or spots in the client’s field of vision, are a symptom of retinal detachment. With retinal detachment, the client is at risk for progressive deterioration of vision. Complete vision loss would be more likely with penetrating or perforating trauma or burn injuries. A red, edematous conjunctiva is more likely with burns. Intense eye pain is more likely with corneal abrasions or a foreign body being on the conjunctiva
A client comes into the emergency department with an eye injury. Which assessment findings suggest that this injury is the result of blunt trauma? Select all that apply.
A) Lid ecchymosis
B) Eye pain and decreased sharpness of vision
C) Photophobia and eye tearing
D) A well-defined bright area of erythema under the conjunctiva
E) A feeling of something in the eye
A, B, D
Explanation: A) Blunt trauma to the eye can cause lid ecchymosis, or a black eye, and subconjunctival hemorrhage, which would be indicated by a well-defined bright area of erythema under the conjunctiva. Decreased visual acuity (sharpness of vision) and eye pain can occur because of trauma-related hyphema, or bleeding into the anterior chamber of the eye. A feeling of something in the eye is typically caused by a foreign body on the conjunctiva. Photophobia and eye tearing are most often seen in corneal abrasions, not blunt trauma.
Which client is most at risk for eye injuries?
A) A firefighter who wears all required safety gear on calls
B) A baseball player who wears nothing over the eyes
C) A self-employed home worker who wears ANSI Z87 eyewear when doing any household cleaning or yard work
D) A construction worker who wears OSHA-required eyewear at all times while on site
Answer: B
Explanation: A) Protective eyewear is estimated to prevent more than 90% of all injuries, but more than 78% of individuals with eye injuries reported not wearing eyewear at the time of injury. Based on this data, the baseball player is most at risk for eye injuries because of the lack of eye protection and the potential for getting hitting in the face with a ball. Although the firefighter and construction workers are in more dangerous lines of work, they are also taking the required steps to protect their eyes and so are less at risk. The home worker is likely to be at least risk for eye injuries and yet still uses appropriate eyewear when cleaning or doing yard work.
The nurse is planning a teaching seminar for parents of school-age children that focuses on eye safety. What should the nurse include in this educational session?
A) All children should wear goggles when playing outdoors at all times.
B) Sunglasses need only be worn during the summer months.
C) Supervise young children when lighting fireworks.
D) Keep sharp objects out of the reach of young children.
Answer: D
Explanation: A) Scissors, knives, and other sharp objects should be kept out of the reach of young children. Parents should not permit preschool-age children to handle or light fireworks, even with supervision. Eye protection should be worn when participating in sports that lead to eye injury, such as baseball or tennis; it is not necessary at all times. Sunglasses should be worn whenever a child is exposed to bright light outdoors, regardless of the season.
A client is diagnosed with a detached retina. Which is the priority nursing diagnosis for this client? A) Risk for Infection B) Anxiety C) Acute Pain D) Risk for Injury
Answer: D
Explanation: A) Immediate intervention is required for a client with a detached retina to prevent permanent injury and preserve vision. Thus, the priority nursing diagnosis for the client would be Risk for Injury. The client will most likely demonstrate anxiety with the loss of vision; however, preventing permanent retinal injury is the priority. Risk for infection would not be a priority until the retina is reattached. A detached retina is not typically accompanied by pain.
) A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority? A) Apply anesthetic drops. B) Apply eye ointment. C) Remove the object. D) Stabilize the object.
Answer: D
Explanation: A) For a severe or penetrating injury, promote rest and stabilize the injured eye by applying an eye pad or gauze dressing loosely over both the affected and unaffected eye. Stabilize any penetrating object, if possible. These measures reduce eye movement and can help preserve the client’s vision. Anesthetic drops would be appropriate prior to the removal of a foreign body from the eye. Removal of a foreign body from the eye is appropriate, but not removal of a penetrating object, which could cause additional tissue damage. Use of eye ointment would be applicable after the removal of a foreign body or for a corneal abrasion.
A client recovering from a penetrating eye injury tells the nurse that some shadows and movement can be seen with the eye. Based on this data, what should the nurse do next?
A) Note a deterioration in vision.
B) Administer ultrasonography to assess the eye for a detached retina.
C) Compare this data to the initial assessment.
D) Note an improvement in vision
Answer: C
Explanation: A) An initial assessment provides valuable information about the effect of the injury on the patient’s vision and a baseline for future comparisons. In this case, if the client had been unable to see through the injured eye and now is able to see shadows and movement, that would indicate an improvement in vision. Deterioration in vision would be indicated by a lack of sight, but there is no way to know whether the client’s condition has improved or worsened without comparing it to the baseline. The client’s ability to see shadows and movement does not indicate the need for ultrasonography, but basic diagnostic testing of the eye’s acuity and pupil reactivity and size is warranted.
The nurse is caring for a client with a corneal abrasion. Which collaborative intervention should the nurse anticipate being included in the client’s care?
A) Bedrest and an eye shield
B) Surgery
C) Applying antibiotic ointment and an eye shield
D) Flushing the eye with normal saline
Answer: C
Explanation: A) Applying antibiotic ointment would be indicated in the care of the client with a corneal abrasion. An eye shield such as an eye patch is further indicated because of the client’s likelihood of rubbing the eye. Flushing the eye with normal saline is indicated for a burn injury to the eye. Surgery is indicated for penetrating injuries to the eye but is usually not necessary for corneal abrasion. Bedrest with an eye shield would be indicated for the care of the client with a blunt trauma to the eye.
The nurse is providing teaching to an older adult client related to avoiding eye injury. What should the nurse identify as an intervention to address the number-one cause of eye injuries in older adults?
A) Turning down the temperature of the client’s home water heater
B) Storing all harsh chemicals out of easy reach
C) Ensuring the client wears protective goggles when engaging in outdoor activities
D) Addressing slippery floors and other fall hazards in the client’s home
Answer: D
Explanation: A) The number-one cause of eye injury in older adults is falling. Primary causes of falls in older adults include slipping on wet surfaces and falling down stairs, so addressing fall hazards such as slippery floors would best prevent eye injuries for this client. Ensuring an appropriate water heater temperature would prevent scalds but does not specifically address risk of eye injury. Wearing eye protection is a good idea when participating in certain sports, but it is not necessary at all times and does not reduce the risk of fall-related injuries. Storing chemicals out of reach is probably not necessary unless there are children in the home; furthermore, keeping chemicals in a place that requires use of a stepstool or ladder may actually increase an older adult’s risk of falls.
Which statement is true?
A) Eye injuries almost always take place in the home.
B) Construction workers have a reduced risk of eye injury because of the many protective measures they take.
C) The pathophysiology of an eye injury depends on the nature of the injury.
D) Eye injuries are relatively uncommon with advances in safety and risk prevention.
Answer: C
Explanation: A) The pathophysiology of an eye injury depends on the nature of the injury. Eye injuries may take place in the home, but they may also occur in other settings such as recreational sports events and the workplace, and adults who are at greatest risk of eye injuries include contractors, woodworkers, welders, and electricians, all of which occupations are heavily involved in construction work. Eye injuries affect more than 2.5 million Americans every year. Each year 50,000 people will permanently lose all or part of their vision as a result of injury.
Foreign objects commonly cause what type of injuries among migrant farm workers? A) Burns B) Blunt trauma C) Penetrating trauma D) Abrasions
Answer: C
Explanation: A) Eye injuries among migrant farm workers are underreported. These individuals are exposed to a variety of risks such as chemicals, machinery, tools, and airborne soil and particulates. In one study, most reported eye injuries among migrant farm workers were penetrating wounds or open wounds, typically caused by foreign objects. An abrasion might not be an open wound, blunt trauma does not break the skin, and burns are not typically caused by foreign objects.
What does it mean to say that a corneal abrasion causes a disruption of the superficial epithelium of the cornea?
A) Such injuries are typically painless.
B) The superficial epithelium is completely removed.
C) The integrity of the superficial epithelium is disturbed.
D) The surface of the cornea sustains penetrating trauma.
Answer: C
Explanation: A) A disruption is a disturbance, in this case to the integrity of the superficial epithelium. An abrasion is not a penetrating injury. Objects that commonly cause corneal abrasion include contact lenses, eyelashes, small foreign bodies such as dust and dirt, and fingernails. Drying of the eye surface and chemical irritants also may result in a corneal abrasion. Superficial corneal abrasions typically heal quickly but are extremely painful. Completely removing the superficial epithelium would destroy the eye.
Which of the following statements best describes the physiologic response of the layers of the eye in response to a penetrating injury?
A) They pull away from the penetration.
B) They reform following the penetration.
C) They degenerate and atrophy immediately.
D) They begin to tear away from one another.
Answer: B
Explanation: A) In a penetrating injury, the layers of the eye spontaneously reapproximate (join together) after entry of a sharp-pointed object or small missile (e.g., a BB) into the globe. They do not pull away from the penetration, immediately degenerate and atrophy, or begin to tear away from one another.
) A client with a long history of type 2 diabetes mellitus complains of occasional coldness and numbness in both hands and both feet. These complaints are suggestive of which condition? A) Idiopathic peripheral neuropathy B) Mononeuropathy C) Polyneuropathy D) Hereditary peripheral neuropathy
Answer: C
Explanation: A) Polyneuropathies, the most common types of neuropathy associated with diabetes, are bilateral sensory disorders. The manifestations appear first in the toes and feet and progress upward. The fingers and hands also may be involved, but usually only in later stages of diabetes. Mononeuropathies are isolated and affect only single nerves; they are commonly associated with injury or trauma. An idiopathic peripheral neuropathy would have no known cause, but for this client diabetes would be a likely cause of neuropathy, and diabetes is not hereditary, so there is no reason to suspect hereditary peripheral neuropathy.
The nurse is providing teaching to a client at risk for acquired peripheral neuropathy. Which of the following activities should the nurse suggest the client modify or avoid to reduce the risk of this condition?
A) Working as an automobile mechanic on weekends
B) Playing tennis every Saturday
C) Drinking one six-pack of beer per day
D) Typing on the computer for several hours each day
Answer: C
Explanation: A) The client has a daily alcohol intake of one six-pack of beer. Alcohol abuse is a risk factor for the development of acquired peripheral neuropathy, so the client should be discouraged from drinking. Typing on the computer for several hours each day might cause some localized nerve compression in the wrists but would not contribute to peripheral neuropathy. Working as an automobile mechanic and playing tennis would not cause peripheral neuropathy.
The nurse is providing client teaching on Guillain-Barré syndrome. Which explanation for a client’s false perception that socks are being worn is accurate?
A) Confusion is a part of this disorder, so the client is simply confused as to whether socks are being worn.
B) This disorder causes a change in sensation that makes the client feel as if socks are being worn.
C) The medications used to treat this disorder cause the client to feel as if socks are being worn.
D) Tactile hallucinations are part of this disorder, so the client is hallucinating that socks are present.
Answer: B
Explanation: A) Changes in sensation related to Guillain-Barré syndrome frequently cause a “stocking-glove” pattern—in which clients feel as if stockings and gloves are being worn when they are not—as well as pain in the hands, feet, and legs. Tactile hallucinations and confusion are not part of the disorder. Medications are not causing the client to feel as if socks are being worn.
A client with peripheral neuropathy complains of leg aches and the inability to be comfortable. Which nursing diagnosis would be a priority for the client at this time?
A) Anxiety
B) Ineffective Peripheral Tissue Perfusion
C) Ineffective Coping
D) Chronic Pain
Answer: D
Explanation: A) The client reports aching legs and an inability to be comfortable. The nursing diagnosis most appropriate for the client at this time would be Chronic Pain. Ineffective Peripheral Tissue Perfusion is the likely reason for the client’s pain and discomfort, but the nurse’s primary interventions for this client will relate to pain management, safety, and comfort, not to directly treating the cause of the pain. The client may have anxiety and be coping ineffectively, but the diagnosis of Chronic Pain is the priority.
The nurse is planning care for an adolescent client recently diagnosed with Charcot-Marie-Tooth syndrome. Which intervention is the highest priority?
A) Managing the client’s chronic pain
B) Reducing the client’s risk for injury
C) Addressing the client’s perfusion problems
D) Relaxing the client to reduce stress
Answer: B
Explanation: A) In the early stage of Charcot-Marie-Tooth syndrome, the disease may manifest in clumsiness due to foot drop and muscle weakness in the feet, ankles, and legs, so addressing risk for injury is the priority for this client. As the client ages, chronic pain will likely become a concern, but not likely at this stage in the disease. Addressing problems with perfusion would not be the priority here, and even if the client feels stress-induced anxiety because of the illness, that is not a priority over ensuring the safety of the client.
The nurse is caring for a client who receives vitamin B12 injections to control her peripheral neuropathy. The client tells the nurse that she recently started experiencing increased tingling in her fingers and toes, and she asks the nurse what this means. How should the nurse reply?
A) “The tingling suggests that you are due for another injection.”
B) “The tingling means that the injections are not producing their intended effect.”
C) “The tingling is a common side effect of B12 injections.”
D) “The tingling is most likely unrelated to your injections.”
Answer: A
Explanation: A) Vitamin B12 injections are given to reduce tingling related to peripheral neuropathy. A recent increase in tingling suggests that the medication has been working but the client is due for another injection soon.
) Which client’s clinical manifestations are most consistent with Guillain-Barré syndrome?
A) A 13-year-old client feels weakness in the feet, ankles, and legs.
B) A 5-year-old client feels leg pain and wants to be carried.
C) A 55-year-old client experiences a lack of hand strength.
D) A 23-year-old client with peripheral neuropathy has poor glycemic control.
Answer: B
Explanation: A) Children younger than 6 years old with Guillain-Barré syndrome may present with a refusal to walk and pain in the legs. The 13-year-old client’s feeling of weakness in the feet, ankles, and legs is likely an early manifestation of Charcot-Marie-Tooth syndrome, whereas the 55-year-old client’s lack of hand strength is likely due to more advanced CMT syndrome. The 23-year-old client with poor glycemic control is likely due to diabetes, which is probably the cause of the client’s peripheral neuropathy.
The nurse is planning teaching for a client diagnosed with diabetic neuropathy. What should the nurse include in this teaching?
A) Set the water heater at 120°F.
B) Avoid hand and foot massages.
C) Use a mirror to inspect feet daily.
D) Increase medication for pain as necessary.
Answer: C
Explanation: A) Using a mirror to inspect the feet daily is recommended because the client may not feel the formation of pressure points, blisters, or ulcers. Setting the water heater at 120°F is incorrect because it is too hot and the client may be scalded because of lack of sensation. Avoiding hand and foot massages is incorrect because this therapy will relax the client, increase the circulation, reduce the need for medication, and increase the psychologic benefits of touch, including the ability to be soothed, comforted, held, and loved. Increasing medication for pain as necessary is incorrect because it can further decrease touch sensation by clouding the sensorium and inducing lethargy, which requires additional supervision and monitoring to ensure safety.
Which of the following statements regarding idiopathic neuropathy is true?
A) Idiopathic neuropathy is hereditary in nature.
B) Idiopathic neuropathy has no known cause.
C) Idiopathic neuropathy is caused by nutritional deficits.
D) Idiopathic neuropathy is caused by disease or illness.
Answer: B
Explanation: A) Idiopathic neuropathies are from an unknown cause and account for up to 30% of neuropathies. These neuropathies are not hereditary and not caused by any identifiable factor such as nutrition or illness.
Which degree of alcohol use has been implicated in the development of alcohol-related neuropathy? A) Chronic and heavy B) Short term and light C) Intermittent and severe D) Acute and toxic
Answer: A
Explanation: A) Alcoholic neuropathy is damage to the nerves that results from long-term excessive use of alcohol, and so chronic and heavy are the best terms to describe the alcohol use that cause this type of peripheral neuropathy. This type of alcohol use is not short term, light, intermittent, or acute.
) Which statement regarding risk factors for peripheral neuropathy is accurate?
A) Extremely short people are at the highest level of risk for developing peripheral neuropathy.
B) Height is a risk factor for women but not a proven risk factor for men.
C) Height is a risk factor for men but not a proven risk factor for women.
D) Risk for peripheral neuropathy is proportional to height for both men and woman.
Answer: D
Explanation: A) Height has been identified as a risk factor for the development of peripheral neuropathy, independent of gender or presence of diabetes mellitus. Men who are taller than 167 cm (5 ft 6 in.) and women who are taller than 159 cm (5 ft 3 in.) are at higher risk for developing peripheral neuropathy than individuals of shorter height, and they are at higher risk of amputation if they do develop peripheral neuropathy.
Answer: D
Explanation: A) Height has been identified as a risk factor for the development of peripheral neuropathy, independent of gender or presence of diabetes mellitus. Men who are taller than 167 cm (5 ft 6 in.) and women who are taller than 159 cm (5 ft 3 in.) are at higher risk for developing peripheral neuropathy than individuals of shorter height, and they are at higher risk of amputation if they do develop peripheral neuropathy.
Answer: B
Explanation: A) Nursing informatics is the science of using computers in nursing practice to improve client care by making client information easily accessible for the client and other healthcare workers who are participating in the client’s care. Documenting client information by computer does not necessarily reduce charting time, depending on the system used. The client’s information is protected by privacy laws. Clients have the right to access their medical records regardless of whether they are paper or electronic.
) The nurse is part of the clinical information system committee at a major healthcare organization. When designing a plan to ensure the protection of client information, which approaches should the nurse suggest this committee include in the implementation plan? Select all that apply.
A) Design policies to address password protection and login information.
B) Determine how to handle clients who desire to “friend” staff through social media.
C) Identify applications that interface with smartphones.
D) Create interfaces so that health data can be inputted by the client.
E) Teach users to not leave protected health information unattended.
Answer: A, B, E
Explanation: A) The committee is creating a plan to ensure the protection of client information. The committee needs to design polices for password protection and login information, determine mechanisms to handle clients and staff who communicate through social media, and teach users to not leave protected health information unattended. Identifying applications that interface with smartphones and creating interfaces so that clients can input health data are not approaches to ensure the protection of client information.
The nurse is preparing discharge instructions for a client with a foot wound. How will the clinical information system support this client’s learning needs?
A) Improves documentation about the client’s status
B) Summarizes the list of charges that will appear on the client’s bill
C) Provides a record of all medications received while hospitalized
D) Prints discharge instructions to use for teaching
Answer: D
Explanation: A) The clinical information system provides access to client information and provides data to help the nurse execute the nursing process. This includes printing discharge instructions to use in client teaching. Although different information systems can do all of these things, only printing discharge instructions will support the client’s learning needs.
A rural home health nurse is caring for a client recovering from a myocardial infarction. The client is concerned that the community clinic does not have the ability to provide the necessary monitoring for the health problem. Which response by the nurse supports the use of informatics to meet client needs?
A) “It is not necessary for you to be monitored after a myocardial infarction.”
B) “We can send your information to the cardiologist using telehealth.”
C) “You are right. We will be sending you to the city every month.”
D) “We use an intranet in this facility.”
Answer: B
Explanation: A) Through telehealth advances, clients who live in remote areas can have their information monitored by specialists using computers. Because of this technology, clients do not need to make frequent visits to specialists for monitoring and evaluation of progress. A client who has experienced a myocardial infarction does require monitoring. The intranet is used within an agency or system and is not a tool that can be accessed from the outside.
The nurse is preparing an educational brochure to teach clients how to determine the validity of content obtained from health-related internet websites. Which information should the nurse plan to include in this teaching tool? Select all that apply.
A) Source for the information
B) Sponsor of the website
C) Ways to identify if the site is selling a product
D) Number of visitors to the website
E) Date the content was last reviewed
Answer: A, B, C, E
Explanation: A) When analyzing online information, the source of the information should be validated. The sponsor of the website should be clearly identified. The site should be studied to see if a product is being sold. A date when the data was last reviewed or updated should be visible. It is not necessary to locate the number of visitors to the website.
A client diagnosed with cancer is receiving care through a facility that is 100 miles from the client’s home. After the nurse explains how telehealth will be used to enhance this client’s care, which client statements indicate that teaching about telehealth has been effective? Select all that apply.
A) “I will have to move closer to the provider.”
B) “My health record can stay where I am.”
C) “I can participate in the videoconference.”
D) “I will have to change doctors.”
E) “This will help lower some costs of care.”
Answer: B, C, E
Explanation: A) Using telehealth, the client can live and stay in the home and does not need to move closer to the treatment or monitoring facility. The client will not be required to change healthcare providers. Telehealth allows for the client to participate in a videoconference, keep health records in the home agency, and lower many of the costs that could be incurred with frequent travel.
Which action by the nurse will help minimize the risk of eyestrain when engaging in computerized documentation?
A) Use a firm board to rest the palm.
B) Use an antiglare screen cover.
C) Obtain a paper chart for nursing documentation.
D) Use a lumbar support.
Answer: B
Explanation: A) An antiglare screen cover may decrease the eyestrain that the nurse is experiencing. The nurse will not be allowed to chart on paper because the nursing documentation is electronic. A firm, flat board or hard surface to rest the palm is the best way to protect the wrist from injury. A lumbar support helps with appropriate body posture for the back.
A group of staff nurses is discussing the importance of uniform language within healthcare documentation. Which statement made by the one of the nurses indicates an understanding of uniform language in healthcare documentation?
A) “Uniform language is useful only when communicating with other staff nurses.”
B) “Uniform language is the consistent use of the same terminology among all providers.”
C) “Uniform language decreases the value of nursing interventions in the eyes of other providers.”
D) “HIPAA and HITECH are examples of uniform languages used by nurses.”
Answer: B
Explanation: A) Uniform language is the consistent use of the same terminology among providers, facilities, institutions, and organizations. It is useful when communicating both with nurses and with providers from other disciplines. Uniform language can increase the visibility of nursing interventions and thus increase their value in the eyes of other providers. NANDA, NIC, and NOC are examples of uniform languages used by nurses, not HIPAA and HITECH.
) Which organization specifically focuses on improving healthcare quality, safety, and outcomes through improving the use of information technology (IT) and systems?
A) Healthcare Information and Management Systems Society (HIMSS)
B) American Medical Informatics Association (AMIA)
C) Alliance for Nursing Informatics (ANI)
D) Technology Informatics Guiding Educational Reform (TIGER)
Answer: A
Explanation: A) HIMSS works to improve healthcare quality, safety, and outcomes through improving the use of IT and systems. AMIA is dedicated to developing health informatics that support client care and teaching. ANI supports information leadership, practice, education, policy, and research. TIGER integrates technology and informatics competencies into nursing education and practice.
) What is the primary advantage of electronic reminders in the electronic health record?
A) They help nurses decrease the length of stay.
B) They help nurses increase client safety.
C) They help nurses document assessments.
D) They help nurses track quality metrics.
Answer: B
Explanation: A) The primary direct advantage of electronic reminders is that they help improve client safety, often by reminding nurses to use certain screening tools or complete certain assessments. By increasing safety, these reminders can indirectly reduce length of stay. Note, however, that electronic reminders don’t actually help nurses document assessments, nor do they
Under which circumstance would the use of a geographic information system (GIS) be beneficial for healthcare workers?
A) When sharing a traveling client’s electronic health record (EHR) with an out-of-state provider
B) During a mass casualty incident
C) When tracking the sleep pattern of a client
D) During an influenza outbreak
: D A GIS is used to map where infectious diseases are most likely to spread next so that adequate care can be provided. Although sleep patterns can be tracked using GIS, GIS is more beneficial when comparing sleep patterns in different geographic regions rather than tracking sleep patterns of one individual client. GIS is not typically used when sharing a traveling client’s EHR with an out-of-state provider or during a mass casualty incident.
The nurse is caring for a client who has a condition that is not responding to standard interventions. How could accessing the clinical decision support system (CDSS) help with this client’s care?
A) Provides evidence-based recommendations for care
B) Decreases the need to use critical thinking skills
C) Tells the nurse what the next step should be
D) Supports the nurse’s “gut” instinct when providing care
Answer: A
Explanation: A) A CDSS uses a knowledge base and programmed rules, protocols, and guidelines developed using evidence-based guidelines to match against client data in the electronic health record (EHR) to deliver alerts or recommendations to the provider. The system will not provide a definitive next step for care, and the nurse still needs to use critical thinking skills to determine the best approach for the individual client. The CDSS may or may not support the nurse’s “gut” instinct.
Which best describes how the use of a clinical decision support system can help the nurse plan care for a client with a particular condition?
A) It can help the nurse find out what was done on the previous admission.
B) It can help the nurse identify evidence-based guidelines for this client’s condition.
C) It can help the nurse use standardized nursing language during documentation.
D) It can help the nurse search the internet for information about surgical procedures.
Answer: B
Explanation: A) Nursing care should always be based on evidence-based guidelines, which the nurse can access through a clinical decision support system. Although informatics can help the nurse find out what was done on the previous admission, use standardized language for documentation, and search the internet for information about the surgical procedure, none of these will help the nurse plan evidence-based care.
The nurse on the hospital research committee is assigned the task of compiling information related to the therapeutic and side effects of a specific drug. Which best describes how the nurse can use informatics to gain information about this topic?
A) Search for articles about the drug in the hospital’s library.
B) Email other research committees to find out what they know about the drug.
C) Query electronic health records (EHRs) to determine client responses to the drug.
D) Look up the drug facts in the latest pharmacology textbook.
Answer: C
Explanation: A) Using computers, nurses can now query EHRs to research client responses to drug administration. Searching for articles in the library or looking up drug facts in a textbook does not require the use of informatics. Although emailing does use computers, emailing another research committee for information about a drug is not best practice for nursing research.
The nurse is facing a problem with a long-term care client that is different from anything encountered by the nurse in the past. What nursing action is appropriate prior to taking the problem to the research committee?
A) Perform a review of the literature.
B) Ask the client’s family if this is a recurring issue.
C) Bring the problem up for discussion in the next staff meeting.
D) Ask the physician for assistance.
Answer: A
Explanation: A) When encountering a problem, the nurse can conduct a literature review to find applicable information. Asking the client’s family if the problem is recurring will not help the nurse determine the course of care. The physician is not consulted for nursing problems. A staff meeting may provide some other opinions but will not give the nurse information regarding studies related to the client’s problem.
In preparation for the next quality improvement committee meeting, the nurse accesses the clinical decision support system to run an outcomes report. How should the nurse anticipate the committee using this report?
A) To eliminate unnecessary care
B) To measure the length of hospital stays
C) To assist in modifying policies and procedures
D) To validate appropriate place of treatment
Answer: C
Explanation: A) Outcome tracking helps identify faulty processes and assists in modifying policies and procedures to improve client outcomes for a particular diagnosis or department within a health organization. Utilization review is designed to eliminate inappropriate or unnecessary medical care, length of stay, and place of treatment.
How does the clinical decision support system support human resource functions?
A) Determining if staff are correctly coding client care procedures
B) Identifying staff who are incorrectly charging for resources used for client care
C) Recognizing staff who are not discharging clients according to identified lengths of stay
D) Evaluating the number of staff with licensure due to expire
Answer: D
Explanation: A) Human resource departments can benefit from computerization by tracking personnel within the healthcare system. Professional licenses and credentials expire and must be renewed. It would be a daunting task to keep track of this information manually for a large facility that employs thousands of healthcare professionals. A computerized system can monitor license expiration and when recredentialing of a provider is required. Coding and charging for resources would be used by the billing department. Information about client discharges according to identified lengths of stay would be used in a utilization review.
The nurse administrator of a local hospital is attending training on the new informatics system the hospital will be implementing. Which information should the nurse administrator be able to manage from the dashboard? Select all that apply. A) Staffing B) Budgets C) Clients D) Quality initiatives E) Plans of care
Answer: A, B, D
Explanation: A) Many electronic health records give administrators tools to manage budgets, staffing, quality initiatives, and productivity information. The use of dashboards puts all of this information at the administrator’s fingertips. The dashboard does not include client-specific or identifying information, such as plans of care.
Which factor increases nurses' use of clinical decision support systems (CDSS)? A) Out-of-the-way workstations B) Nursing experience C) Caring for a new client D) Reminder pop-ups
Answer: C
Explanation: A) Nurses tend to use CDSS more frequently when they are caring for a client with which they are unfamiliar. However, nurses tend to decrease use of a CDSS when they have more nursing experience, when there are too many reminders, or when the workstation is not conveniently located.
Which administrative function related to medical records management may be made easier by the use of informatics?
A) Tracking client outcomes
B) Making sure charts are coded correctly
C) Ordering materials and supplies
D) Assigning a client to a hospital room
Answer: D
Explanation: A) All of these tasks are made easier through the use of informatics, but only assigning a client to a hospital room is related to medical records management. Tracking client outcomes is part of quality assurance, making sure charts are coded correctly is the job of the billing department, and ordering materials and supplies is related to facilities management.
What function might be made easier for healthcare organizations through the use of a computerized contract management system?
A) Tracking changes in reimbursement rates
B) Sharing information between billing systems
C) Managing material and supply inventories
D) Planning organizational budgets
Answer: A
Explanation: A) A computerized contract management system helps facilities track rates of reimbursement and real-time changes in policies for different health insurance plans. Financial systems help share information between billing systems, manage material and supply inventories, and plan organizational budgets.
) Several nurses are discussing the use of electronic medical records when providing client care. Which statements by the nurses indicate that they understand the advantages of electronic health records (EHRs)? Select all that apply.
A) “The record reduces the cost of healthcare.”
B) “The record allows trending of client progress.”
C) “Client education can be documented in the system.”
D) “Quality metrics can be observed to reduce readmission rates.”
E) “Coordination of care is improved.”
Answer: B, C, D, E
Explanation: A) Electronic health records can assist the nurse by allowing trending of client progress, documentation of client education, and observation of quality metrics to help decrease readmission rates. Electronic health records also allow improved coordination of care between providers because they are all working off one chart. The use of the electronic health record does not directly reduce the cost of healthcare.
The nurse is providing discharge instructions about medications and exercise to a client who was hospitalized with a serious medical condition. Which action by the nurse ensures that the client is fully informed?
A) Make sure a relative attends the discharge teaching session.
B) Repeat the discharge teaching sessions twice.
C) Ask the physician to reinforce teaching prior to discharging the client.
D) Print the discharge instructions and hand them to the client prior to discharge.
Answer: D
Explanation: A) Most hospitals and agencies have computer-generated discharge instructions that the nurse can print to give the client to refer to when at home. This not only prevents calls, but gives the client confidence. Repeating the instructions does not help the client at home. Relatives can forget as easily as the client. It is not the physician’s place to reinforce teaching.
Which statement regarding the term “point of care” is correct?
A) “Point of care” refers to the use of a portable device to provide care near the client.
B) “Point of care” refers to the location that nurses document care of the client.
C) “Point of care” refers to care that takes place away from the client.
D) “Point of care” refers to care that takes place in the client’s home.
Answer: A
Explanation: A) One of the selling points of an electronic health record is that charting at point of care is possible, which helps to increase efficiency. Point of care refers to interventions or testing that takes place using a transportable, portable, or handheld device near the client. Point of care does not refer to the location where documentation takes place or to care that takes place away from the client or specifically in the client’s home.
Advances in technology have made what information available to healthcare providers at the client's bedside? A) Vital signs B) Radiologic images C) Allergy alerts D) Dietary restrictions
Answer: B
Explanation: A) Even before many advances in technology, nurses and other healthcare providers had access to the client’s current vital signs, allergy alerts, and dietary restrictions by viewing the client’s paper chart at the client’s bedside. However, they usually could not view radiologic images at the bedside. Now, with advances in technology, results from laboratory and radiologic exams can often be viewed at the client’s bedside.
What is one advantage of the standardization of health records in relation to client education?
A) It allows the nurse to print information for the client rather than reviewing the information in person.
B) Families can receive education rather than clients in order to ensure that the client receives proper care at home.
C) Clients can receive the same education about their condition regardless of where they receive treatment.
D) Clients can look up their health information at home after discharge.
Answer: C
Explanation: A) Standardization of the health record allows clients to receive the same education about their condition regardless of where they receive treatment. Standardization does not negate the nurse’s responsibility to review the information in person with the patient or family. Both families and client should receive education as appropriate, regardless of standardization. Clients looking up their health information at home does not depend on standardization of health records.
The nurse is caring for an older adult. Which age-related changes should the nurse identify as increasing the risk of dry skin? Select all that apply. A) Reduction in elastin B) Depleted moisture in epidermal cells C) Decreased size of sebaceous glands D) Thinner subcutaneous skin layer E) Poor nutrition
Answer: B, C, E
Explanation: A) As the individual ages, moisture transfer from the dermis to the epidermis declines. This contributes to a dry, rough skin appearance. Sebaceous glands also decrease in size with age, resulting in skin that is dry and easily bruised, damaged, or broken. Poor nutrition could also cause dry skin. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult’s thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.
The nurse observes flakes of greasy white dandruff in a client's hair. The nurse should correctly identify this as which type of secondary lesion? A) Nodule B) Macule C) Scales D) Crusts
Answer: C
Explanation: A) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, to gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.
The nurse presses a finger into swollen skin tissue on a client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin integrity? A) Poor turgor B) Ascites C) Peripheral edema D) Hypothermia
Answer: C
Explanation: A) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Skin turgor is the skin’s elasticity and is assessed by gently pinching the skin over the sternum or collarbone. Skin temperature is assessed through palpation.
A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered? A) Skin biopsy B) Culture C) Wood's lamp D) Patch test
Answer: B
Explanation: A) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood’s lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.
A middle-age adult client states to the nurse, “I do not want to have brown spots on my skin like my parents did as they got older.” Which instruction by the nurse is appropriate?
A) Spend at least 15 minutes each day in the sun.
B) Increase the intake of calcium.
C) Increase the intake of dietary fat.
D) Avoid the sun or use a sunscreen to reduce skin damage.
Answer: D
Explanation: A) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun. The intake of dietary fat or calcium will not affect the development of liver spots.
The nurse is providing care to a client who is experiencing skin inflammation and pruritus. Which of the following medications does the nurse anticipate will be prescribed for this client? Select all that apply. A) Erythromycin B) Bacitracin C) Gentamycin D) Desoximetasone E) Desonide
Answer: D, E
Explanation: A) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.
) A nurse educator is teaching a group of student nurses about newborn skin and factors that relate to this concept. Which statement will the educator include in the teaching session?
A) “The newborn’s skin is about 40% to 60% thinner than an adult’s skin at birth.”
B) “The newborn’s skin contains less water than an adult’s and has tightly attached cells.”
C) “The newborn’s thicker skin decreases absorption of harmful chemical substances and topical medications.”
D) “The newborn’s skin has a greater percentage of underlying subcutaneous fat compared to adults.”
Answer: A
Explanation: A) The newborn’s skin is about 40% to 60% thinner than an adult’s, which makes the newborn’s skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn’s skin contains more water than an adult’s and has loosely attached cells. The newborn’s skin has less subcutaneous fat compared to adults.
A nurse is working in a skilled nursing facility and is performing an assessment on an older adult client. The nurse notes that the client has hypopigmentation of the skin on both hands. The nurse should recognize that this condition is related to which age-related skin change?
A) Hyperplasia of melanocytes
B) Decreased perfusion of the dermis
C) Increased permeability of the epidermal layer
D) Hyperplasia of capillaries
Answer: A
Explanation: A) Hyerpigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.
What does the nurse anticipate finding in a client with impetigo?
A) An infection in the hair follicles
B) Loss of skin color in blotches or sections
C) An itchy rash with clusters of fluid-filled vesicles
D) A fungal infection in the skinfolds
Answer: C
Explanation: A) Impetigo is a superficial skin infection common on the face, arms, and legs of children that presents as an itchy rash with clusters of fluid-filled vesicles that rupture easily. Ruptured vesicles develop a honey-colored crust over the lesions. Folliculitis is an infection of hair follicles. Vitiligo is a loss of skin color in blotches or sections that occur when the cells that produce melanin die or stop functioning. Candidiasis is a fungal infection commonly known as thrush and found in skinfolds.
A patient with an allergy to latex develops contact dermatitis following an examination during which the nurse wore latex gloves. Which best describes the associated pathophysiology?
A) An immune response that leads to issues with tissue integrity
B) Impaired tissue integrity that leads to an immune response
C) Impaired tissue integrity that leads to an infection
D) Decreased perfusion that leads to issues with tissue integrity
Answer: A
Explanation: A) Allergic reactions are an example of an immune response that leads to issues with tissue integrity. Impaired tissue integrity, such as a cut, can lead to an immune response, but that is not the case in this scenario. If left untreated or exposed to bacteria or other infectious agents, the dermatitis could lead to an infection, but there is no evidence of that in this scenario. Decreased perfusion can lead to tissue damage or death, but not dermatitis.
) What impact might corticosteroids have on tissue integrity?
A) It may increase sensitivity to sunlight, leading to sunburns.
B) It may cause thinning of the skin, making skin more easily injured.
C) It may make skin appear shiny and lose its hair distribution.
D) It may cause the skin to become overly dry.
Answer: B
Explanation: A) Some medications, such as corticosteroids, cause thinning of the skin, making it much more easily damaged. Antibiotics, chemotherapy drugs, and some psychotherapeutic drugs increase sensitivity to sunlight and can predispose the individual to sunburns. Impaired peripheral arterial circulation in the lower extremities may produce skin that appears shiny and has lost its hair distribution. Excessive cleansing can cause the skin to become overly dry.
A nurse is conducting a skin assessment of a patient. Upon palpating skin temperature, the nurse notes the skin is warm and red. This is an abnormal sign that may be indicative of
A) decreased hydration.
B) decreased blood flow to the skin.
C) inflammation and elevated body temperature.
D) hypothyroidism.
Answer: C
Explanation: A) Warm, red skin indicates inflammation and elevated body temperature. Decreased skin temperature is indicative of decreased blood flow to the skin. Excessively dry skin is indicative of hypothyroidism. Poor skin turgor is indicative of decreased hydration.
The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU) with a partial-thickness thermal burn. When planning care for this client, which should the nurse consider regarding this type of burn?
A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only.
B) A superficial partial-thickness burn extends from the skin’s surface into the papillary layer of the dermis.
C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation.
D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn.
Answer: B
Explanation: A) A superficial partial-thickness burn extends from the skin’s surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.
) A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant
Answer: C
Explanation: A) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.
A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation?
A) Decreased osmotic pressure in the burned tissue
B) Reduced microvascular permeability at the site of the burned area
C) Increased potassium in the intracellular compartment
D) Inability of the damaged capillaries to maintain fluids in the cell walls
Answer: D
Explanation: A) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is a shifting of fluid volume that is the direct result of lost cell wall integrity at the injury site and in the capillary bed. There is an increase in microvascular permeability at the burn site. The osmotic pressure is also increased, causing fluid accumulation. Potassium ions leave the intracellular compartment, putting patients at risk for cardiac dysrhythmia due to hypokalemia.
Which data supports the nurse’s concern that a client is at a high risk for a burn injury? Select all that apply.
A) Part-time employment at a convenience store
B) Diagnosis of hypertension
C) Age 71 years
D) Uses public transportation for grocery shopping
E) Currently smokes one pack of cigarettes per day
Answer: C, E
Explanation: A) Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, senses of smell and hearing, and because of impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client’s risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client’s risk of experiencing a burn injury.
An older adult client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client’s intake and output, which of the following should be taken into consideration?
A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase.
C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins.
D) The amount of urine output will be greatest in the first 24 hours after the burn injury.
Answer: B
Explanation: A) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.
A client who sustained burns to both lower extremities reports feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time? A) Ineffective Coping B) Powerlessness C) Anxiety D) Situational Low Self-Esteem
Answer: B
Explanation: A) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low self-esteem, ineffective coping, or anxiety.
The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? Select all that apply. A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care
Answer: A, C, E
Explanation: A) Nursing care for the client during the acute stage of burn injuries will include wound care, nutritional therapy, and pain management. Fluid resuscitation occurs during the emergency phase of burn care. Psychosocial support will be needed once the client has stabilized.
) The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status? A) Creatine phosphokinase (CPK) B) Blood urea nitrogen (BUN) levels C) Hemoglobin D) Albumin level
Answer: D
Explanation: A) Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent on the fluid status.
The nurse is caring for a client who is to receive mechanical debridement of burn wounds. Which methods should the nurse anticipate using to complete this treatment? Select all that apply.
A) Homograft
B) Application of a topical agent to dissolve necrotic tissue
C) Irrigation of the burn wounds
D) Application of wet-to-dry gauze dressings
E) Hydrotherapy
Answer: C, D, E
Explanation: A) Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.
How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg?
A) Place the client flat with the affected extremity abducted.
B) Elevate the head of bed 30 degrees
C) Maintain the head of bed flat
D) Elevate the affected extremity
Answer: D
Explanation: A) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client’s long-range prognosis.
The nurse is planning to provide care to extended family members spanning three generations who are being treated for burn injuries after a fire. Based on an understanding of lifespan factors, the nurse should anticipate that which of the following is true?
A) The 38-year-old pregnant mother is more likely to require an allograft than the other members of the family.
B) The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members.
C) The 14-year-old son is less likely to experience edema associated with his injuries than older members of the family.
D) The 6-year-old daughter is more likely to go into burn shock than the other members of the family.
Answer: B
Explanation: A) The older adult population is more likely to suffer burns to a greater percentage of their TBSA than other age groups, largely because their skin is so much thinner and therefore more delicate than that of younger individuals. The other assumptions cannot be made based on patient age alone and depend on the depth and extent of the burns, which is information that is unavailable at this time.
An adult burn patient is brought in to the intensive care unit (ICU) for treatment. Prior to sustaining the injury, the client was considered underweight for her height. The nurse understands that this may have important implications for the client because
A) she will have lower fluid resuscitation calculations than patients of normal weight.
B) she will be at greater risk for developing cardiac or renal insufficiencies.
C) she will require more supportive care than patients who are normal weight.
D) she will lose as much as 20% of her preburn weight during rehabilitation.
Answer: D
Explanation: A) During the acute and rehabilitative phases of the burn injury, the patient loses as much as 20% of preburn weight. This has significant implications for all patients, especially those who are underweight at the time of injury. Fluid resuscitation calculations are based on the time of injury, not body weight. Patients with a past medical history of cardiac or renal problems are at an increased risk for cardiac and renal insufficiency regardless of weight. Children and older adults require more supportive care than other client populations because of differences in their skin and healing, not because of their body weight.
) An adult burn patient is receiving fluid resuscitation of warm, lactated Ringer’s solution during the first 24 hours following injury. The client’s hourly urine output is being monitored to determine whether the resuscitation is adequate. The most recent reading is 1.10 mL/kg/hr. The nurse understands that this amount of urine output is
A) slightly higher than the normal range.
B) slightly lower than the normal range.
C) within the normal range.
D) extremely low.
Answer: A
Explanation: A) In adult patients with burn injuries who are receiving fluid resuscitation, urine production of 0.5-1 mL/kg/hr is considered normal. Therefore, the nurse would understand that this patient’s output is slightly high.
A burn patient is currently in the acute stage. When did this stage begin, and when will it end?
A) It began with the onset of the burn injury and will end with fluid resuscitation.
B) It began with wound closure and will end when the patient’s health is fully restored.
C) It began with the start of diuresis and will end with the closure of the burn wound.
D) It began with the onset of the burn injury and will end with the closure of the burn wound
Answer: C
Explanation: A) The acute stage begins with the start of diuresis and ends with the closure of the burn wound, either by natural healing or by use of skin grafts. The emergent/resuscitative stage begins with the onset of the burn injury and ends with successful fluid resuscitation. The rehabilitative stage begins with wound closure and ends when the patient returns to the highest level of health restoration, which may take years.
A client has a pressure injury on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use? A) Partial-thickness loss of dermis B) Nonblanchable erythema C) Suspected deep tissue injury D) Full-thickness tissue loss
Answer: C
Explanation: A) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Nonblanchable erythema refers to a stage 1 pressure injury. Partial-thickness loss of dermis refers to a stage 2 pressure injury. Full-thickness tissue loss refers to stage 3, stage 4, and unstageable pressure injuries.
A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client?
A) Clean the pressure injury as needed.
B) Use hydrogen peroxide for chemical debridement of wound bed as needed.
C) Maintain the head of the client’s bed at 30 degrees.
D) Avoid placing the client in the side-lying position
Answer: D
Explanation: A) The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client’s medical condition and other restrictions. In addition, the nurse should clean the client’s pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.
) An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown?
A) Using the bed sheet to slide the client up in bed
B) Placing the bed in reverse Trendelenburg position
C) Using the client’s arms to pull the client up in bed
D) Lifting the client, using the client’s legs and arms for assistance
Answer: D
Explanation: A) The client is of advanced age and has poor skin turgor. Both of these factors put the client at increased risk for alterations in skin integrity, including damage due to shearing forces. To prevent shearing of the client’s skin, the nurse should lift the client up in bed, using the client’s legs and arms for assistance. Pulling the client up in bed may cause skin shearing. Sliding the client on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg position will not facilitate appropriate positioning of the client in the bed.
The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? Select all that apply. A) Age 54 B) Body temperature within normal limits C) Low serum albumin level D) Continence of urine and stool E) Prescribed bedrest
Answer: C, E
Explanation: A) Risk factors for pressure injury development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure injury development. Although advanced age increases the risk of pressure injuries, this client is only 54 years old. Finally, normal body temperature does not increase the client’s risk for pressure injury development.
An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage 1 pressure injury forming on the client’s sacrum. Which action by the nurse is appropriate to reduce the progression of this injury?
A) Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side.
B) Apply a heat lamp to the area to increase circulation.
C) Apply a dry dressing to the pressure injury.
D) Maintain the head of the bed at a 45-degree angle.
Answer: A
Explanation: A) Keeping the head of the bed at an angle of 30 degrees or less decreases pressure on the sacrum. An angle of 45 degrees would be too severe and could exacerbate pressure injury formation on the sacrum. Dry dressings are not indicated with this stage of pressure injury. Heat lamps are no longer used in the treatment of pressure injuries because they do not provide therapeutic benefit.
A client has a documented stage 3 pressure injury on the right hip. Which nursing diagnosis is most appropriate for this client?
A) Impaired Skin Integrity
B) Risk for Injury
C) Impaired Tissue Integrity
D) Ineffective Peripheral Tissue Perfusion
Answer: C
Explanation: A) Because a stage 3 pressure injury involves tissue, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure injuries result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity involves the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury, so Risk for Injury does not apply.
When planning care for a client at risk for developing pressure injuries, which intervention(s) should be included? Select all that apply.
A) Initiate a frequent toileting schedule.
B) Raise the client’s heels off the bed.
C) Turn the client every 4 hours.
D) Use inflatable doughnut-style devices to reduce pressure on the sacrum.
E) Massage pressure areas with lotion every 4 hours.
Answer: A, B
Explanation: A) Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and the potential for skin breakdown. The client’s heels should be raised off the bed to remove pressure on this area of the body. The client should be turned at least every 2 hours. Massaging pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, because they increase pressure and reduce perfusion to affected areas.
The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor?
A) The rubber doughnut pressure relief device was not delivered by central supply.
B) The client’s serum albumin increased over the last month.
C) A right side-back-left side-back turning schedule was used.
D) Nurses did not document disinfection of the wound with alcohol at each dressing change.
Answer: C
Explanation: A) Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.
) A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate?
A) “I will need to get an order from the physician.”
B) “Using the doughnut can cause skin breakdown.”
C) “You will need to wait until discharge, then use the doughnut at home.”
D) “I will obtain the device for you.
Answer: B
Explanation: A) Use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened with use of the device, but this is due to the loss of sensation. Use of a doughnut-style device should be avoided whether at the hospital or at home.
A client’s spouse reports the presence of a reddened area on the client’s coccyx and wants to massage the area. Which response by the nurse is appropriate?
A) “I will need to obtain an order from the healthcare provider to perform a massage.”
B) “Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care.”
C) “I will record these findings in the medical record.”
D) “Massage may actually cause more harm to a potentially compromised area of skin.”
Answer: D
Explanation: A) Redness may indicate the presence of a stage 1 pressure injury. Evidence suggests that massage over bony prominences like the coccyx can cause or worsen deep tissue trauma in patients at risk for a pressure injury. Massage should thus be restricted when problems are noted. Even when appropriate and therapeutic for a client, massages do not require a healthcare provider’s order.
A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility’s older adult clients are at elevated risk for pressure injuries. Which response is best?
A) “As people age, their epidermis becomes more elastic. This increased elasticity makes older adults’ skin more susceptible to damage.”
B) “As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries.”
C) “Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity.”
D) “Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity.”
Answer: D
Explanation: A) Several factors put older adults at increased risk for pressure injuries; these include loss of lean body mass; generalized thinning of the epidermis; decreased strength and reduced elasticity of the skin; and diminished venous and arterial flow due to aging vascular walls. Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands also increases the risk for impaired skin integrity in older adults. Although excess body heat is a risk factor for pressure injuries, older adults tend to have lower average body temperatures than younger clients.
) What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4
Answer: B
Explanation: A) A stage 2 pressure injury is characterized by partial-thickness skin loss involving the dermis. It presents as a shallow open ulcer with a viable, moist wound bed that is red or pink. Granulation tissue, slough, and eschar are not present. A stage 2 injury may also present as an intact or open serum-filled blister.
Softening of the skin as a result of prolonged wetting or soaking is also referred to as A) maceration. B) debridement. C) excoriation. D) shearing.
Answer: A
Explanation: A) Maceration involves softening of the skin due to prolonged wetting or soaking. Excoriation is loss of the superficial layers of the skin. Debridement is the removal of necrotic material from a wound. Shearing occurs when one layer of tissue slides over another.
Which of the following clients would be the most appropriate candidate for autolytic debridement?
A) A 47-year-old client with a stage 2 pressure injury
B) A 68-year-old client with a suspected deep tissue injury
C) A 71-year-old client with a stage 1 pressure injury
D) A 59-year-old client with a stage 3 pressure injury
Answer: D
Explanation: A) Debridement, regardless of type, is typically reserved for pressure injuries with full-thickness tissue loss. This includes stage 3 pressure injuries, stage 4 pressure injuries, and (in some cases) unstageable pressure injuries. Thus, only the client with a stage 3 injury would be an appropriate candidate.
A client has a laceration that was closed with tissue adhesive. By what process will this wound heal? A) Tertiary intention B) Secondary intention C) Delayed primary intention D) Primary intention
Answer: D
Explanation: A) In primary intention wound healing, the edges of the wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds. Secondary intention healing involves wounds that cannot be approximated and that must “heal in.” These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring. With tertiary intention healing, also called delayed primary intention healing, wounds are left open for 3 to 5 days to allow edema or infection to resolve before being closed by sutures, staples, or adhesive skin closures.
A client recovering from abdominal surgery tells the nurse that “something popped” in his abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What actions by the nurse are appropriate? Select all that apply.
A) Notify the client’s surgeon.
B) Pack the client’s wound with nonadherent gauze.
C) Turn the client onto his abdomen.
D) Position the client in bed with his knees bent.
E) Cover the incision with a large, saline-soaked dressing.
Answer: A, D, E
Explanation: A) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound, and the client should not be turned onto his abdomen.
An older adult client diagnosed with chronic obstructive pulmonary disease (COPD) is scheduled for a total knee replacement. What should the nurse include in this client's plan of care to address the risk of an alteration in tissue integrity? A) Monitor urine output. B) Assess postoperative wound healing. C) Restrict protein intake. D) Expect purulent drainage.
Answer: B
Explanation: A) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. Furthermore, regardless of their chronic disease status, older adults often experience slowed healing as a result of normal cellular and molecular changes. Thus, it is critical that the nurse regularly assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need adequate protein for wound healing, so protein intake should not be restricted.
A client is admitted to the hospital with a gunshot wound to the leg. Which nursing diagnosis is a priority? A) Situational Low Self-Esteem B) Risk for Infection C) Anxiety D) Ineffective Coping
Answer: B
Explanation: A) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.
The nurse is planning care for a client with a surgical wound. Which goal related to the surgical wound is most appropriate for this client?
A) The client will discharge to home as soon as possible.
B) The client will resume independent activities of daily living (ADLs).
C) The client will increase ambulation.
D) The client will regain intact skin.
Answer: D
Explanation: A) This client has impaired skin integrity because of a surgical wound. An appropriate goal of care would be for the client to experience wound healing to achieve intact skin. For a client who otherwise has good health, the other goals are appropriate, but they are not directly related to the surgical wound. However, for some patients, discharge to home, resuming independent ADLs, and increasing ambulation may not be appropriate goals.
The nurse is assessing a client with a surgical wound. Which finding indicates that care has been effective for this client?
A) The client’s temperature is 100°F.
B) The client performs wound care independently.
C) There is only a scant amount of purulent drainage on the dressing.
D) A small area of erythema and edema is present.
Answer: B
Explanation: A) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.
An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the client’s nutritional needs?
A) Assist with deep-breathing exercises.
B) Medicate for pain prior to dressing changes.
C) Request a dietary consult.
D) Encourage ambulation.
Answer: C
Explanation: A) The nurse should consult with a dietitian to identify ways to improve the client’s intake to support wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.
A client has a wound on the left lateral aspect of the thigh. Which action by the nurse would best promote wound healing for this client?
A) Positioning the client to keep weight off the wound
B) Positioning the client with weight directly on the wound
C) Restricting fluids
D) Enforcing strict bedrest
Answer: A
Explanation: A) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation, and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.
A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. Three days after the debridement, the client's surgical wound was closed with staples that are aiding in healing. Given this information, which of the following terms should the nurse use when documenting this client's care? A) Primary intention healing B) Secondary intention healing C) Tertiary intention healing D) Quaternary intention healing
Answer: C
Explanation: A) Wounds that are left open for 3-5 days to allow edema or infection to resolve or to permit exudate to drain and then are closed with sutures, staples, or adhesive skin closures undergo tertiary intention healing. Primary intention healing occurs where tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.
A nurse working in the intensive care unit (ICU) is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a well-approximated midline surgical incision that has numerous staples, and the nurse notes a "healing ridge" is present. Based on this information, the incision is currently in which phase of the healing process? A) Inflammatory phase B) Proliferative phase C) Maturation phase D) Synthesis phase
Answer: B
Explanation: A) The proliferative phase, which is the second phase in the healing process, extends from day 3 or 4 to about day 21 postinjury. If the wound is sutured, a raised “healing ridge” appears under the intact suture line. There is no synthesis phase in the healing process, and the other choices are incorrect.
Which statement about wound care across the lifespan is correct?
A) “When applying transparent dressings on older adult clients, do not hold the skin taut, because doing so can cause damage.”
B) “In young children, staph bacteria and fungi are the most common causes of infection in minor wounds.”
C) “Pressure injuries and contact irritation are rare among newborns and infants in NICUs.”
D) “As compared to younger clients, older adults have a heightened inflammatory response, which can contribute to delayed wound healing.”
Answer: B
Explanation: A) Of these options, the only accurate statement is that the two major infectious agents affecting the skin of children are Staphylococcus and fungi. The rest of the statements are not valid. Specifically, the skin of older adult clients should be held taut when applying transparent dressings; pressure injuries and contact irritation are common among hospitalized newborns and infants; and older adults have a delayed inflammatory response as compared to younger clients.
) Hemostasis and phagocytosis are characteristic of which stage of the wound healing process? A) Inflammatory phase B) Proliferative phase C) Granulation phase D) Maturation phase
Answer: A
Explanation: A) The inflammatory phase of wound healing is initiated immediately after injury and lasts 3-6 days. Two major processes occur during this phase: hemostasis and phagocytosis. The inflammatory phase is followed by the proliferative and maturation phases. There is not a granulation phase of wound healing, although formation of granulation tissue occurs during the proliferative phase.
Which of the following findings suggests that a wound is infected with pyogenic bacteria? A) Sanguineous exudate B) Serous exudate C) Serosanguineous exudate D) Purulent exudate
Answer: D
Explanation: A) Purulent exudate is more commonly called pus, and it is created by microorganisms known as pyogenic bacteria. In contrast, sanguineous exudate consists of large amounts of red blood cells; serous exudate is clear or straw colored and has few cells; and serosanguineous exudate consists of both clear and blood-tinged drainage.
Which of the following medications may be discontinued in a client who is experiencing delayed wound healing? A) Oral prednisone B) Topical antibiotics C) Topical growth factors D) Oral antibiotics
Answer: A
Explanation: A) Oral prednisone is a steroid. Steroids are known to interfere with healing, so it is likely that use of these drugs may be discontinued. In contrast, topical and oral antibiotics may be appropriate for clients with delayed wound healing, because they can help prevent infection. Topical growth factors may also be applied to a wound in an attempt to “jump start” the healing process.
) The nurse is assessing a client’s spirituality. Which of the following findings would suggest that the client experiences spirituality as a source of strength? Select all that apply.
A) The client uses the telephone to inform family members of an unwanted diagnosis.
B) The client reads spiritual material every evening.
C) The client asks to watch a religious service on television.
D) The client says she has no desire to meet with a chaplain.
E) The client tells the nurse she is convinced she will be punished in the afterlife.
Answer: B, C
Explanation: A) Regularly reading spiritual material and asking to watch a religious service on television are actions that suggest the client views spirituality as a source of strength. In contrast, focusing on possible punishment in the afterlife would suggest that the client is experiencing spiritual distress. Lack of interest in meeting with a chaplain might indicate spiritual distress, or it might indicate that the client either places little emphasis on spirituality or feels that his or her spirituality is a private matter. Discussing an unwanted diagnosis on the phone is unrelated to spirituality.
While hospitalized, a client learns that a close friend has died suddenly. The client is crying and asking, "Why, God?" The nurse should correctly identify that the client is demonstrating which type of spiritual distress? A) Physiologic B) Psychologic C) Treatment-related D) Situational
Answer: D
Explanation: A) Factors that may be associated with or contribute to an individual’s spiritual distress include situational concerns, physiologic problems, and treatment-related concerns. Situational factors include the death or illness of a significant other, inability to practice one’s spiritual rituals, or feelings of embarrassment when practicing them. Physiologic problems include having a medical diagnosis of a terminal or debilitating disease. Treatment-related factors include recommendation for treatment, surgery, dietary restrictions, or isolation. Psychologic is not a factor that contributes to spiritual distress.
The nurse is providing care to a client diagnosed with type 2 diabetes mellitus. The client wishes to take Communion but must fast for 1 hour prior to receiving it. Which action by the nurse is most appropriate?
A) Contact the healthcare provider to suggest an alternative form of nutrition because the client is refusing to eat or drink.
B) Provide the client with breakfast and morning medication and encourage the client to eat and take Communion some other time.
C) Find out when the hospital clergy will be distributing Communion and adjust the client’s medications and breakfast accordingly.
D) Suggest that because the client is hospitalized, eating and drinking will not affect the Communion.
Answer: C
Explanation: A) The nurse should follow the client’s expressed wishes regarding spiritual care and should not pressure them to relinquish any of their beliefs or practices. To support the client’s spiritual needs, the nurse should find out when Communion will be distributed and adjust the medications and breakfast accordingly. The nurse should not suggest that eating and drinking will not affect Communion. The nurse should not ignore the client’s needs by providing medication and breakfast. The nurse should also not contact the healthcare provider to suggest alternative forms of nutrition, because the client is not refusing to eat or drink but wants to delay eating and drinking until after Communion.
While assessing a client's spiritual needs, the nurse asks, "What spiritual beliefs are important to you?" This question represents which step of the FICA assessment model? A) Community B) Address C) Implication D) Faith
Answer: D
Explanation: A) Within the FICA assessment model for spirituality, faith is assessed by asking the question “What spiritual beliefs are important to you?” Implication is assessed by asking the client, “How is your faith affecting the way you cope?” Community is assessed by asking, “Is there is a community of like-minded believers with which you routinely meet?” Address is assessed by asking the client, “How can the healthcare team support your spiritual needs?”
When receiving nursing care, the client states, “I drink a small glass of warm water mixed with the juice of one lemon every morning because it helps to heal my body.” Which action by the nurse is appropriate when providing care to this client?
A) Tell the client that cold water is better metabolized by the body.
B) Instruct the client that lemon juice is really a dose of vitamin C that helps with healing.
C) Provide the warm water and juice of a lemon.
D) Suggest the client delay the water and lemon until after morning medications.
Answer: C
Explanation: A) The nurse should follow the client’s expressed wishes regarding spiritual care. To support the client’s beliefs about healing, the nurse should provide the client with the warm water and lemon juice. The nurse should not instruct the client about the benefits of lemon juice being vitamin C. The nurse should also not suggest that cold water be used instead. Asking the client to delay drinking the water and lemon juice will not support the client’s spiritual needs.
Which questions are appropriate for the nurse to ask when assessing the spiritual beliefs of a client? Select all that apply.
A) “How will being sick interfere with your religious practices?”
B) “Would you like a visit from your spiritual counselor or the hospital chaplain?”
C) “Are any particular religious practices important to you?”
D) “How is your faith helpful to you?”
E) “Because you indicated you are Catholic, I suppose you fast every Friday?”
Answer: A, B, C, D
Explanation: A) The question related to fasting on Friday is inappropriate because it assumes that a client follows all the practices of the client’s stated religion. All other questions are appropriate for the nursing student to ask a client during an admission assessment while assessing spiritual and religious beliefs.
A nurse is admitting a client to the oncology unit. During the admission assessment, when the nurse asks the client about religious preference, the client states, “I am an atheist.” The nurse should recognize that the client holds which belief?
A) The client believes that there is one God.
B) The client believes that there is more than one god.
C) The client believes that the existence of God has not been proven.
D) The client does not believe in any god.
Answer: D
Explanation: A) An atheist is an individual who does not believe in any god. Monotheism is the belief in the existence of one God. Polytheism is the belief in more than one god. An agnostic is an individual who doubts the existence of God or a supreme being or who believes that the existence of God has not been proven.
The family members of a critically ill client tell the nurse, "We believe in the power of prayer. Prayer connects us all and makes us stronger. We will continue to pray that our loved one recovers." This statement suggests that the family is demonstrating which of the following characteristics? A) Good family support system B) Spiritual well-being C) Denial D) Spiritual distress
Answer: B
Explanation: A) Through their statement, the family members express the belief that they are connected by a higher power. They also say they draw strength from this belief. This is evidence of spiritual well-being, not spiritual distress. The family may or may not be denying the client’s health status. Although this statement indicates that the family turns to a higher power for support, it does not reveal anything about the family’s overall support system.
Prior to being discharged, a client tells the nurse, "I trust you and the rest of the medical team, and I think the prescribed treatment is going to work. I'm ready to embrace life, and I'm looking forward to celebrating the holiday season in a few months." This statement suggests that the client is experiencing which of the following? A) Spiritual well-being B) Denial C) Conflict D) Apprehension
Answer: A
Explanation: A) The client speaks of trusting relationships, hope, and a feeling of being alive and ready to embrace what the future brings. This suggests the client is in a state of spiritual well-being. The client’s statement is not suggestive of denial, apprehension, or conflict about the future.
A client was recently diagnosed with alcoholic liver cirrhosis. During a regular checkup, the client tells the nurse, "This is God's punishment for all those parties I went to when I was younger." The nurse should recognize that this religious view could have a negative effect on what other nursing concept? A) Addiction B) Legal Issues C) Stress and Coping D) Digestion
Answer: C
Explanation: A) Clients can use religion as either a positive or a negative coping strategy. Negative expressions of religious coping include statements like “God is punishing me.” If the client is addicted to alcohol, the diagnosis and religious belief may stimulate the client to give up alcohol, which would not be a negative effect. There are no legal issues present due to this client’s statement. This religious view is unlikely to affect the client’s digestive processes, although the disease itself may reduce metabolism associated with digestion.
The nurse is caring for a devout Muslim client who is near death. The nurse should be prepared for which request from the client related to religious beliefs?
A) Turn the client’s head or body toward Mecca.
B) Have a spiritual leader perform the Anointing of the Sick.
C) Read the client the Tibetan Book of the Dead.
D) Perform a ritualistic bath for cleansing the body.
Answer: A
Explanation: A) Muslims who are dying often want their body or head turned toward Mecca, and they are encouraged to say the prayer recognizing their loyalty to Allah. Roman Catholics may request having a spiritual leader perform the sacrament of Anointing of the Sick. Tibetan Buddhists may read the Tibetan Book of the Dead within 7 days after death, but not before death. Ritualistic bathing of the body is usually performed by some religions, including Muslims, after death, not before death.
) The nurse is caring for an 8-year-old client who has been in the hospital repeatedly due to complications from leukemia. The nurse understands that the family is very religious, and the client often speaks about God’s care for her. Which age-appropriate nursing intervention should the nurse implement that can help the child express her spirituality?
A) Help the child reminisce about fun experiences earlier in life.
B) Provide the child with tools to draw and color pictures.
C) Provide the child with tools to produce a music video.
D) Support parent-child bonding to encourage attachment.
Answer: B
Explanation: A) Nurses can support the spiritual well-being of the child by age-appropriate activities that allow nonverbal expression of faith, including drawing, coloring, painting, play, or music, depending on the child’s interests or energy level. Producing a music video is more appropriate for adolescent clients. Supporting parent-child bonding is more appropriate for infants. Reminiscing about the past is more appropriate for older adults.
The nurse is caring for an older adult client with advanced dementia. The family often mentions that the client was very spiritual earlier in life and loved to sing. What could the nurse suggest to the family to help support the client’s religious needs?
A) They should help the client reminisce about spiritual events early in life.
B) They should encourage the client to compose lyrics or write music to a new spiritual song.
C) They should sing some of their favorite songs to the client.
D) They should bring in a recording of some of the client’s favorite spiritual songs for him to listen to.
Answer: D
Explanation: A) One way that clients with dementia can worship is through various art forms, including music. This is an especially appropriate option for this client, given his history of spirituality and a love of singing. Letting the client listen to some favorite of his spiritual songs will give him an opportunity to enjoy an enriching spiritual experience without being pressured to participate, generate new ideas, or remember events from the past.
The nurse is providing care to a client who has just received a diagnosis of cancer. Which findings would suggest that the client is experiencing spiritual distress? Select all that apply.
A) Client is observed crying with children.
B) Client tells the nurse that he feels hopeless.
C) Client discusses possible outcomes with healthcare provider.
D) Client turns off a religious show on the TV and stares out the window.
E) Client is talking quietly with spouse.
Answer: B, D
Explanation: A) Spiritual distress may be characterized by expressions of a deficit in meaning, purpose, hope, forgiveness, or intimacy with the divine, or by anger or a lack of interest about previously spiritually nurturing persons or resources. Telling the nurse he feels hopeless and turning off a religious TV show indicates spiritual distress. The other actions are normal responses to a cancer diagnosis.
The nurse is planning care for a hospitalized client. Which activities should the nurse identify as appropriate to support the client’s spiritual needs through presencing? Select all that apply.
A) Being available to the client
B) Sharing about a time when the nurse overcame a similar situation
C) Reading a newspaper at the nurse’s station
D) Stating personal religious beliefs
E) Listening to the client
Answer: A, E
Explanation: A) Features of presencing include being available to the client and listening. Stating personal religious beliefs, reading a newspaper, and sharing about a time when the nurse overcame a similar situation are not characteristics of presencing.
A nurse is caring for a client who was recently diagnosed with a terminal illness. Which statement made by the client would indicate to the nurse that the client is in spiritual distress?
A) “I am not sure why this is happening but I believe God has a plan for me.”
B) “I wish I did not have cancer but I believe that it is happening for a reason.”
C) “My children don’t go to church and they are having a difficult time dealing with my diagnosis.”
D) “People tell me things happen for a reason, but why is God doing this to me?”
Answer: D
Explanation: A) The statement “But why is God doing this to me?” is reflective of spiritual distress. The client is not demonstrating being able to find a purpose and is also demonstrating a disconnect between herself and her higher spirit. The other answers do not indicate spiritual distress of the client.
A nurse enters a client’s room to assess why the alarm on an IV infusion has sounded. As the nurse checks the IV equipment, the client says he would like someone to pray with. How should the nurse address the client’s spiritual needs while providing necessary IV care?
A) The nurse should focus her attention solely on the infusion, because it is more important at this time than the client’s prayer request.
B) The nurse should nod in response to the client’s request while taking care of the infusion.
C) While taking care of the infusion, the nurse should offer to call a clergy member.
D) After assessing that the alarm is not an emergency, the nurse should offer to pray with the client.
Answer: D
Explanation: A) The nurse can best address this client’s spiritual needs by being fully present with the patient and not being distracted by other tasks such as assessing the IV infusion. Although the nurse’s first priority is to assess that the alarm is not an emergency, she can then stop and be fully present by listening to the client’s request and offering to pray with the client. The other options do not indicate that the nurse is fully present with the client.
The nurse is performing a holistic assessment of a client. Which observations indicate that the client is experiencing spiritual distress? Select all that apply.
A) The client is sitting in a chair before breakfast reading the Bible.
B) The client states he has lost his faith in God since he’s gotten ill.
C) The client is watching a religious program on the television.
D) The client is crying, pacing, and mumbling about God being angry with him.
E) The client is overheard arguing with clergy about the existence of God.
Answer: B, D, E
Explanation: A) The client who states a loss of faith in God after getting ill, the client who is crying, pacing and mumbling about God being angry with him, and the client who is overheard arguing with clergy about the existence of God may all be experiencing spiritual distress. The client who is observed sitting in a chair before breakfast reading the Bible or who is watching a religious program on the television is demonstrating a behavior of spiritual health.
The nurse recognizes that a client is experiencing spiritual distress due to the need to receive a blood transfusion. The nurse should also identify the need to provide interventions for what other nursing diagnosis? A) Decisional Conflict B) Chronic Confusion C) Acute Pain D) Self Neglect
Answer: A
Explanation: A) Some clients have religious beliefs that prevent them from receiving any blood products. If a client has a life-threatening condition that requires a blood transfusion, the client may have spiritual distress related to the conflict between religious beliefs and lifesaving medical treatments. This causes Decisional Conflict for the client. This conflict between beliefs and treatments would not likely cause Chronic Confusion, Acute Pain, or Self Neglect.
The nurse is caring for a client in spiritual distress. The client has met with the hospital chaplain but did not find it beneficial. The nurse recognizes that outside assistance from the client’s own spiritual advisor may be helpful. What should the nurse do before making an appointment with the advisor?
A) Consult with the primary care provider to find an available counselor.
B) Ask the client’s permission to contact the counselor.
C) Call the hospital chaplain to come speak with the client.
D) Advocate with the primary care provider to offer spiritual care to the client.
Answer: B
Explanation: A) The client’s permission is needed before seeking an outside counselor in order to protect the client’s right to confidentiality. Therefore, the nurse should ask the client’s permission before contacting the counselor. The nurse does not need to consult with the primary care provider to find an available counselor, nor should the nurse ask the primary care provider to offer spiritual care to the client. Although the nurse could call the hospital chaplain to come speak with the client, this is not required before scheduling an appointment with an outside counselor.
While helping a client with the evening meal, the nurse observes the client close his eyes, bow his head, and murmur words of thanks and praise. What should this behavior suggest to the nurse?
A) The client did not want the nurse to leave.
B) The client was asking that the meal be better than the last.
C) The client is confused.
D) The client was praying before eating.
Answer: D
Explanation: A) The client’s behavior of bowing the head, closing the eyes, and murmuring words of thanks and praise are indications that the client was praying. The client was not demonstrating confusion. The nurse has no way of knowing if the client was asking that the meal be better than the last. The client was not delaying the nurse so that she did not leave.
A client requests that surgery be delayed for several days until after a period of Holy Days has concluded. Which action by the nurse supports this client’s request?
A) Remind the client that one’s health is more important than following Holy Days.
B) Provide the client with alternative forms of treatment to replace having surgery.
C) Suggest the client think about whether having the surgery is the right decision, as the client is willing to delay it now.
D) Communicate the client’s request to the surgeon.
Answer: D
Explanation: A) To support the client’s need to avoid surgery during Holy Days, the nurse should communicate the client’s request to the surgeon. The nurse should not remind the client that health is more important than following Holy Days or suggest that the client consider not having surgery. The nurse should also not provide the client with alternative forms of treatment to replace having surgery, as this is outside the nurse’s scope of practice.
) A client who is scheduled for surgery wants to continue to wear a religious medallion. Which actions by the nurse support the client’s religious needs? Select all that apply.
A) Keep the medallion on the client but remove it once anesthesia is provided.
B) Ask the client if wearing a medallion is going to ensure a successful surgery.
C) Document that the medallion is being worn by the client.
D) Suggest the client not wear the medallion because it will most likely be lost.
E) Explain that the medallion can be safety pinned to the client’s gown.
Answer: C, E
Explanation: A) The nurse should explain that the medallion can be safety pinned to the client’s gown. This approach would ensure compliance with the client’s religious needs as well as safety for any surgical intervention planned for the client. The nurse should also document that the medallion is being worn by the client. The nurse should not remove the medallion after anesthesia is provided. The nurse should not tell the client that the medallion will be lost if worn or confront the client by asking if the medallion is going to ensure successful surgery.
A client is abstaining from meat and dairy products during Lent and refuses to select these items when making meal choices. Which actions by the nurse support the client’s nutritional and religious needs? Select all that apply.
A) Ask the healthcare provider to discuss the impact of the restricted diet on the client’s health.
B) Provide soy milk products as supplements.
C) Add protein powder supplements to the client’s water pitcher.
D) Ask the client what foods are typically consumed during this period of time.
E) Consult with a dietitian for food choices to meet the client’s needs.
Answer: D, E
Explanation: A) The best interventions would be for the nurse to consult with a dietitian for food choices to meet the client’s health and religious needs and ask the client what foods are typically consumed during this period of time. The nurse should not provide soy milk products as supplements because the client may not like them. The nurse should not ask the physician to talk about the restricted diet with the client. The nurse should also not provide protein powder supplements in the client’s water pitcher.
The nurse is preparing to discharge a client from the hospital. Which actions by the client indicate that her religious needs were met during the hospitalization? Select all that apply.
A) Requesting and attending religious services in the hospital chapel
B) Thanking the nurse for contacting a priest to visit while hospitalized
C) Asking nurse for additional supplies to change dressings while at home
D) Refusing home care services because the client’s daughter is a nurse and a Sunday school teacher
E) Asking the nurse whom to call if problems occur after surgery
Answer: A, B
Explanation: A) Evidence that a client’s religious needs were met while hospitalized would be the client thanking the nurse for contacting her priest and the client requesting and attending religious services in the hospital chapel. Asking for additional supplies to change dressings at home, asking whom to call if she has any problems at home, or telling the nurse that she will not need home care are unrelated to spiritual care
The nurse is developing a plan of care for a devout Muslim client. Which intervention should the nurse anticipate being a priority for this client?
A) The client will be able to participate in observing Sabbath.
B) The client will be able to participate in daily prayer with a rosary.
C) The client will be able to participate in reading the Torah.
D) The client will be able to participate in prayer at specific times without interruption.
Answer: D
Explanation: A) Nurses working with Muslim clients should be aware that many Muslims pray five times a day, and when developing the plan of care they should take prayer times into consideration if this is important to the client. Observing the Sabbath is common to Christianity and Judaism. Daily prayer with a rosary is common to Catholicism. Reading the Torah is specific to Judaism.
The nurse is providing care to several clients. Which clients are most likely to request a vegetarian diet due to religious beliefs? Select all that apply. A) A Catholic client B) A Jewish client C) A Hindu client D) An Episcopalian client E) A Seventh-Day Adventist client
Answer: C, E
Explanation: A) Of the individuals listed, the Hindu and Seventh-Day Adventist clients are most likely to be vegetarian because of their religious beliefs. The Jewish, Episcopalian, and Catholic clients may opt to abstain from certain types of food, but these clients are not likely to be vegetarian because of their religious beliefs.
) The nurse is providing care to a Catholic client who describes herself as "extremely devout." Which treatment option is most likely to cause spiritual distress for this client? A) Blood transfusion for anemia B) Specialized cardiac diet C) Elective termination of pregnancy D) A below-the-knee amputation
Answer: C
Explanation: A) Elective termination of pregnancy, or abortion, is the treatment most likely to cause a devout Catholic client spiritual distress. Blood transfusion, specialized cardiac diet, and below-the-knee amputation are less likely to cause this client spiritual distress because they are not prohibited by Catholic teaching
The nurse is caring for a client who is actively engaged in an organized religion. Based on this statement, the nurse knows that which of the following statements is most likely true?
A) The client believes in the presence of only one god.
B) The client knows other individuals from the same religion who may be available to offer emotional and spiritual support.
C) The client lives by the moral code of the Ten Commandments.
D) The client will require time set aside for prayer several times each day, and the nurse will need to work around this schedule.
Answer: B
Explanation: A) Individuals who are actively engaged in a specific religion are usually part of a religious community. Members of this community are often called upon for emotional and spiritual support, especially during times of hardship or illness. Without knowing the client’s specific religion, the nurse cannot assume that the client believes in the presence of only one god, that the client will need to set aside specific times each day for prayer, or that the client lives by the moral code of the Ten Commandments.
) A young client is brought into the emergency department by a friend who says the client was “beat up” at school. The client has bruising and lacerations to the face and torso. The client is reluctant to provide the names of parents or a home address. What can the nurse safely assume about this client?
A) The client does not want the individual who did the beating to get in trouble.
B) The client does not know his parents.
C) The client does not want the school to get in trouble.
D) The client is a victim of interpersonal violence.
Answer: D
Explanation: A) The client’s reluctance to provide parents’ names or address could suggest the client is a victim of child abuse from parents rather than a victim of bullying at school. Either way, the client is clearly a victim of interpersonal violence. It is unlikely that the client does not know his parents. It is also unlikely that the client does not want to get the school or the individual who did the beating in trouble.
A client with a walking disability tells the nurse that going out alone at night is not an option for fear of being a target for a crime. Which has the client identified based on this data? A) A protective factor B) A risk factor C) A vulnerability factor D) A precipitating factor
Answer: C
Explanation: A) Vulnerability factors increase one’s risk of being a victim of violence. The client with a walking disability avoids the possibility of a crime by not going out alone at night. A protective factor decreases the risk of perpetration and victimization. Risk factors increase the potential that one will perpetrate violence on others. Precipitating factors are those that give rise to a specific incident of violence.
A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply.
A) Explore options for self-development.
B) Improve quality of life by increasing self-esteem.
C) Explore options for help.
D) Convey safety.
E) Determine immediacy of danger.
Answer: C, D, E
Explanation: A) Short-term interventions for abuse include determining the immediacy of danger, conveying that the client has the right to be safe, and exploring options for help. Exploring options for self-development and improving the quality of life by increasing self-esteem are long-term interventions for abused adults.
) After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic violence. Which action should occur next? A) Conducting a team assessment B) Medicating for anxiety as prescribed C) Notifying the police D) Treating the injuries
Answer: A
Explanation: A) If the nursing assessment reveals possible domestic violence, a primary focus will be treating the injuries. However, treatment is often done by a team, which means a team assessment needs to be conducted before treatment can take place. The police may need to be notified later. The degree of anxiety will determine whether the client needs medication.
The nurse is caring for a client who is the victim of domestic violence and is visited by the spouse in the hospital. The client has indicated that she plans to return to her spouse when she leaves the hospital. Which action by the nurse supports the client when the spouse is present?
A) Call the police to have the spouse arrested for assault.
B) Refuse to permit the spouse to visit with the client.
C) Call security to have the spouse removed.
D) Ask the client if there is anything that is needed at this time.
Answer: D
Explanation: A) The nurse needs to maintain a nonjudgmental attitude when caring for victims of abuse and their family members. The nurse should ask the client if there is anything that is needed at this time. The nurse should not refuse to let the spouse visit unless it is the client’s wish to do so. The nurse should not contact security or the police unless requested by the spouse.
) The nurse is providing care to a child who has suffered abuse. Which nursing actions are appropriate? Select all that apply.
A) Ask the child what he did to cause his parents to beat him so badly.
B) Tell the child that the individual who hurt them is a bad person.
C) Follow protocols for mandatory reporting.
D) Remind the child that he did nothing wrong.
E) Ask the child what really happened.
Answer: C, D
Explanation: A) The priority nursing consideration regarding the abused child is to ensure the immediate safety of the child. Beyond that, the abused child needs to be encouraged to talk about the abuse but must also be protected from having to provide multiple reports. The nurse working with the abused child needs to say that he or she believes the child’s story; the nurse also must reassure the child that he or she has done nothing wrong. The nurse should avoid making negative comments about the abuser and must follow established protocols for mandatory reporting, documentation, and use of available support services.
The nurse is discharging a client who was admitted for surgery for a compound ulnar fracture that occurred during a conflict with the client's spouse. The client states, "I hope this cast comes off before summer. Last night my husband promised me he is going to take me to Hawaii this summer. After he broke my jaw, we went to Rome." Based on this data, which phase of violence is the client experiencing? A) The tension phase B) The abusive phase C) The honeymoon phase D) The reconciliation phase
Answer: C
Explanation: A) The tension phase of the cycle of violence occurs when communication fails and tension builds. The abusive phase occurs when there is a violent incident. The honeymoon phase occurs when the aggressor shows love and affection. The cycle of violence will continue unless intervention occurs, and there is no reason for the client to expect it will stop or anticipate reconciliation and healing.
The school nurse is leading a discussion on violence with a group of adolescents. Which factors could the school nurse indicate as protective factors that may decrease the risk of violence? Select all that apply. A) Involvement in the community B) Participation in family activities C) Residing in an impoverished community D) Academic failures at a young age E) Success in school
Answer: A, B, E
Explanation: A) Involvement in the community, participation in family activities, and success in school are all examples of protective factors. Protective factors decrease the risk of violence perpetration and victimization. Residing in an impoverished community is a predisposing factor. Academic failure at a young age is a risk factor for becoming a perpetrator.
A client is brought into the emergency department after being in a motor vehicle crash. The client has suffered traumatic injury that may involve multiple body systems. Which assessment is the highest priority for this client?
A) Breathing and ventilation
B) Circulation with hemorrhage control
C) Airway maintenance with cervical spine protection
D) Disability and neurologic assessment
Answer: C
Explanation: A) When caring for the trauma victim, the nurse must always prioritize assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse’s first concern be airway maintenance with cervical spine protection.
What type of communication should the nurse employ when caring for a client who has suffered trauma? A) Assertive communication B) Therapeutic communication C) Passive communication D) Aggressive communication
Answer: B
Explanation: A) Nurses need to employ therapeutic communication to help clients work through the stress and fear of the traumatic event and ultimately accept that the situation they experienced cannot be reversed. Nurses should never use passive or aggressive communication techniques with clients. Assertive communication may be helpful in some circumstances, but it is not as important as therapeutic communication.
The nurse is caring for several clients in the emergency department. Which individual is a victim of community violence?
A) A 32-year-old woman who was beaten by her spouse
B) A 20-year-old man who was shot during a gang dispute
C) A 6-month-old girl who was abused by her mother
D) A 76-year-old man who was neglected at a care facility
Answer: B
Explanation: A) Gang violence is a type of community violence, so traumatic injuries sustained during a gang dispute would be categorized as community violence. The other examples are related to interpersonal violence.
) An individual who has experienced which type of trauma is likely to be most resilient? A) Intimate partner violence B) Bullying C) Rape D) Natural disaster
Answer: D
Explanation: A) Generally, survivors of natural disasters show resilience, and the stress responses do not become chronic or debilitating. Bullying and intimate partner violence may be ongoing, persistent stressors that prevent resiliency. Rape is an extreme traumatic event that may take months to years to recover from
A child is admitted to the hospital with physical injuries. Which assessment findings would indicate that the child is a victim of abuse? Select all that apply.
A) Confusion
B) Missing teeth
C) Apprehension when other children cry
D) Abrasions to the mouth, lips, and genitalia
E) Dehydration
Answer: B, C, D
Explanation: A) Clinical manifestations of child abuse include abrasions to the mouth, lips, and genitalia; missing teeth; and apprehension when other children cry. Dehydration and confusion are manifestations of elder abuse.
The nurse is providing care for a 2-year-old client. When assessing the client’s risk for abuse, which factors increase this client’s risk? Select all that apply.
A) The child has bruises on the knees and shins.
B) The child’s parents are married.
C) The child is less than 3 years old.
D) The child is deaf.
E) The child’s parents are unemployed and receive medical assistance.
Answer: C, D, E
Explanation: A) Risk factors for child abuse include poverty, age less than 3 years, and child disability or condition that requires a great deal of care. Marriage of the parents and bruises on the knees and shins are not risk factors for abuse.
A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate? A) Powerlessness B) Risk for Other-Directed Violence C) Ineffective Health Maintenance D) Chronic Low Self-Esteem
Answer: A
Explanation: A) Powerlessness is indicated when the client feels an inability to change the pattern or to leave the situation. The victim may experience health maintenance problems as a result of experiencing domestic violence; however, this is not the primary diagnosis. Some victims will experience self-esteem issues, which are secondary to their feeling of having little or no control over their lives. The client is not at high risk for other-directed violence but is rather at high risk to experience it.
The nurse is providing care for a client who experienced several fractures as a result of intimate partner violence. Which intervention is the most appropriate to include when planning care for the client?
A) Assist the client to devise a safety or escape plan.
B) Encourage the client to take charge of the situation.
C) Offer to contact outpatient services if the client promises not to return home after discharge.
D) Make it clear to the spouse that the couple needs to see a therapist.
Answer: A
Explanation: A) A client who has been victimized by a partner should have a safety plan. This has the highest priority as the client’s life is in danger. The client has no control over the partner, and suggesting that the couple needs to see a therapist may escalate the situation. Encouraging the client to take charge is too general a statement to be helpful; the client needs specific tools to develop a safety plan. It may not be safe and feasible for the client to leave the situation right away, and resources should not be withheld if a client is unable to promise not to return home.
A client who has experienced domestic violence in the past has decided to stop participating in counseling. Which client statement would indicate that therapy has been effective?
A) “Everyone knows what my problems are, and there is nothing I can do about it.”
B) “I am functioning fine now but I know that when problems come up again, I will ask for help.”
C) “My friends tell me that I have improved so this is a good time to stop.”
D) “It is so draining to deal with the same painful issues all of the time.”
Answer: B
Explanation: A) The client acknowledging that future problems will come up indicates that the client has gained insight into problems. The client’s willingness to ask for help shows that the client is prepared to continue with counseling when new problems arise. Stating that the process is draining and painful suggests that little progress has been made and that the client is looking to avoid the pain. Stating that there is nothing than can be done is fatalistic. Basing termination of treatment on the statements of others places emphasis on others and not on self-evaluation.
An older adult client is brought into the emergency room after experiencing a fall. The nurse suspects elder abuse. Which assessment findings support the nurse's suspicions? Select all that apply. A) Poor hygiene B) Dehydration C) Intracranial trauma D) Fecal impaction E) Dislocations
Answer: A, B, D, E
Explanation: A) The nurse suspecting elder abuse would assess for clinical manifestations associated with elder abuse. Some of those clinical manifestations are constant hunger or malnutrition, poor hygiene, social isolation, contractures, dehydration, fecal impaction, fractures, sprains, or dislocations. Intracranial trauma is not a typical clinical manifestation of elder abuse; however, it is a clinical manifestation of child abuse.
The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client’s upper back with several bruised areas. Which nursing action is the most appropriate?
A) Contact adult protective services.
B) Call the healthcare provider immediately.
C) Assess the client’s cultural traditions.
D) Contact the client’s family.
Answer: C
Explanation: A) The most appropriate action for the nurse at this time is to assess the client’s cultural traditions. The practice of cupping is generally practiced by many Asian cultures, as well as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then using heat to create suction; often this is performed to promote blood flow and overall healing. The result of the procedure can be circular red welts or even dark bruising, which are often found along the individual’s back. This treatment is not abusive in nature, but rather a form of healing.
A pediatric nurse is caring for an 8-month-old client. While making rounds, the nurse enters the room and finds the infant’s father violently shaking the infant. The father attempts to make it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant’s arms and legs. What is a priority action for the nurse to take?
A) Discuss what the nurse witnessed with the infant’s mother.
B) Discuss what the nurse witnessed with the other nurses.
C) Report what the nurse witnessed and assessed to the authorities.
D) Call security to remove the father from the room.
Answer: C
Explanation: A) Because of mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate authorities. It would not be appropriate at this time to discuss the findings with the infant’s mother or with other nurses. The nurse should also not call security to remove the father from the room until after the abuse has been reported.
Which of the following is a common element of abuse experienced by the victim? A) Accidental injury B) Feelings of control C) Humiliation D) Manipulation
Answer: C
Explanation: A) Common elements of abuse include humiliation, intimidation, and physical injury. Injury associated with abuse is not accidental. Feelings of control and use of manipulation tactics are related to the perpetrator, not the victim.
Which theory states that individuals learn violent tendencies through association with others and a reinforcement of abusive behaviors? A) Social learning theory B) Psychopathology theory C) Neurobiology theory D) Environmental theory
Answer: A
Explanation: A) Social learning theory explains that individuals learn violent tendencies through association with others and a reinforcement of the abusive behavior. Psychopathology theory suggests that some individuals who experience personality disorders and mental illnesses participate in family violence as a result of these illnesses. Neurobiology theory asserts that genetics plays a role in anger modulation and emotion control. Environmental theory is not related to the etiology of abuse.
) Which diagnostic test might the healthcare team use to determine the full extent of an abuse victim's injuries if the victim complains of abdominal pain? A) Ultrasound B) X-ray C) MRI D) Blood test
A) An ultrasound or CT scan of the abdomen can check for abdominal or organ injuries. An MRI of the spine will show spinal injuries. X-rays can detect fractured bones. Blood tests may be used to detect sexually transmitted diseases.
An older adult man is transported to the emergency department after a motor vehicle crash. Which risk factors for the older adult could have contributed to the crash? Select all that apply. A) Unsafe driving practices B) Preexisting health conditions C) Speeding D) Texting E) Reduced sensory perception
B, E
Explanation: A) Older adults are at risk of motor vehicle crashes due to preexisting health conditions and decreased sensory perceptions. Younger adults are at risk of motor vehicle crashes due to unsafe driving practices, speeding, and texting or other distractions.
The nurse is planning care for a client with multiple lower extremity fractures sustained from a motor vehicle crash. Which is an appropriate client goal for the nurse to include in the plan of care?
A) The client will have adequate urine output.
B) The client will regain mobility.
C) The client will participate in self-care activities.
D) The client will be discharged to home.
Answer: B
Explanation: A) The client has sustained multiple lower extremity fractures. A goal of care for this client is for the client to regain mobility. An adequate urine output is important, but healing the client’s fractures needs to be a goal of care. Participating in self-care activities and being discharged to home are also important; however, because the client sustained multiple fractures to the lower extremities, one goal of care must be focused on the client regaining mobility.
A client was admitted to the hospital after a crush injury to the chest. The client sustained multiple rib fractures, a collapsed lung, and several skin abrasions. After the client is stabilized, which nursing intervention would be a priority for this client?
A) Monitor urine output.
B) Assess vital signs.
C) Perform passive range of motion to all extremities.
D) Assist to deep breathe and cough every 2 hours.
Answer: D
Explanation: A) The client has thoracic injuries and might be reluctant to deep breathe and cough because of pain. The nurse needs to ensure that the client breathes deeply and coughs every 2 hours to mobilize secretions and prevent respiratory complications. Monitoring urine output and assessing vital signs are important but not the priority at this time. The client may be able to perform active range of motion for all extremities, so this intervention may or may not be indicated.
A client is admitted to the emergency department with an incomplete spinal cord injury after a fall from a roof. Which prescription does the nurse anticipate to decrease inflammation and nerve damage? A) Hydrocodone (Vicodin) B) Ibuprofen (Motrin) C) Methylprednisolone (Medrol) D) Xylocaine (Lidocaine)
Answer: C
Explanation: A) Methylprednisolone (Medrol) is given to clients with spinal cord injuries to decrease inflammation and prevent nerve damage. Hydrocodone (Vicodin) is a pain relief medication. Ibuprofen (Motrin) is an anti-inflammatory given to clients to reduce swelling, such as joint swelling. Xylocaine (Lidocaine) is injected into the affected muscle to relieve pain and muscle spasms, such as muscle spasms related to whiplash.
The nurse at a local hospital is conducting a safety workshop for expectant parents addressing newborn injury prevention and car seat safety. Which statement made by a parent indicates a need for further teaching?
A) “My newborn should be in a car safety seat every time he is in the car.”
B) “My baby can ride facing forward as long as he is in a convertible car seat suitable for an infant.”
C) “My newborn should ride in a rear-facing car seat.”
D) “Never place a rear-facing car safety seat in the front seat with an active passenger air bag.”
Answer: B
Explanation: A) Infants should always ride in a rear-facing car seat, even if it is a convertible seat suitable for an infant. Therefore, the statement relating to the infant facing forward is incorrect and indicates a need for further instruction. The other statements are correct and indicate no need for further education.
A nurse is developing a plan of care for a client with traumatic injuries after a natural disaster. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?
A) Provide active or passive exercises at least once every 8 hours.
B) Encourage coughing, deep breathing, and incentive spirometry.
C) Assist the client in turning at least every 2 hours.
D) Assist the client in turning at least every 8 hours.
Answer: C
Explanation: A) Assisting the client to turn at least every 2 hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications. Turning the client every 8 hours will not reduce the risk of integumentary complications. Encouraging exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications.
What would the nurse working in the emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply. A) Airway maintenance B) Obtaining medical history C) Ventilation assistance D) Hemorrhage control E) Hypothermia prevention
What would the nurse working in the emergency department identify as clinical priorities for the treatment of a client with a gunshot wound? Select all that apply. A) Airway maintenance B) Obtaining medical history C) Ventilation assistance D) Hemorrhage control E) Hypothermia prevention
A client is brought into the emergency department after being assaulted. The provider suspects that the client has a spinal cord injury. Which diagnostic tests does the nurse anticipate based on the data collected? Select all that apply.
A) Computed tomography (CT) scan
B) X-ray
C) Ultrasound
D) Magnetic resonance imaging (MRI)
E) Positron emission tomography (PET) scan
Answer: A, D
Explanation: A) Both MRIs and CT scans can be used to assess spinal cord injuries, among other injuries. An x-ray will be performed for potential fractured bones. An ultrasound is performed if internal bleeding is suspected. A PET scan is used to look for disease within the main organs of the body
Which cause of multisystem trauma is the leading cause of injury death in the United States? A) Poisonings B) Motor vehicle crashes C) Assault D) Natural disasters
Answer: A
Explanation: A) Poisonings are the leading cause of injury death in the United States, and all causes of fatal injuries are also causes of multisystem trauma. Motor vehicle crashes are also a major concern because of the significance of injuries sustained, but they are not the leading cause of injury death. Assault and natural disasters are not leading causes of injury death.
A client lost consciousness after being hit by a falling piece of equipment on a work site. What type of injury should the nurse assess this client for as the highest priority? A) Fractured bones B) Traumatic brain injury C) Whiplash D) Spinal cord injury
Answer: B
Explanation: A) Loss of consciousness is a sign of traumatic brain injury, and any injury to the brain should be assessed with highest priority. Fractured bones and spinal cord injury may also need to be assessed depending on the location of the injury and the client’s other clinical manifestations, but these would be a lower priority than assessing for traumatic brain injury. Whiplash usually results from a motor vehicle crash, so assessing for whiplash would be low in priority.
If a pregnant woman sustains multisystem trauma, in which order should assessment occur?
A) Primary assessment of the mother, secondary assessment of the mother, primary assessment of the fetus
B) Primary assessment of the mother, primary assessment of the fetus, secondary assessment of the mother
C) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the mother
D) Primary assessment of the fetus, primary assessment of the mother, secondary assessment of the fetus
Answer: B
Explanation: A) If a pregnant woman sustains multisystem trauma, the best treatment for the fetus is resuscitation of the mother. Therefore, the mother should be assessed first, then the fetus. Once both have been assessed and stabilized, then the secondary assessment of the mother should be performed.
During the assessment, the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang. Which should the nurse assume regarding the client’s behavior?
A) The client thought there was an earthquake.
B) The client was reacting to the loud noise as a form of a flashback.
C) The client wanted to check the cause of the loud noise.
D) The client thought the assessment was concluded.
Answer: B
Explanation: A) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client’s reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise
The nurse suspects a client is experiencing posttraumatic stress disorder when which are noted during the assessment process? Select all that apply.
A) Observed family member being raped and murdered
B) Restores antique automobiles as a hobby
C) Lives with spouse and has a garden
D) Has a history of anxiety disorder
E) Recently terminated from employment
Answer: A, D, E
Explanation: A) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.
A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder (PTSD)? Select all that apply. A) Difficulty sleeping B) Hypovigilance C) Alcohol abuse D) Aggressive behavior E) Hair pulling
A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder (PTSD)? Select all that apply. A) Difficulty sleeping B) Hypovigilance C) Alcohol abuse D) Aggressive behavior E) Hair pulling
A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman. Which nursing diagnosis is the priority for this client? A) Fear B) Anxiety C) Post-Trauma Syndrome D) Ineffective Coping
Answer: C
Explanation: A) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
The nurse is caring for a client who was diagnosed with posttraumatic stress disorder 4 months ago. Which should the nurse include in the client’s plan of care?
A) Guidelines on conducting activities of daily living
B) Information on the treatments available
C) Referral to local employment agency
D) Information on the need for adequate exercise
Answer: B
Explanation: A) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client’s symptoms. Referral to the local employment agency may or may not be necessary.
The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder. Which outcomes would indicate the interventions in the plan of care have been effective? Select all that apply.
A) The client takes a sedative at least four times a day.
B) The client has been sleeping throughout the night.
C) The client keeps all of the lights on at home.
D) The client verbalizes future plans with family and friends.
E) The client will not enter a car with fewer than three people.
Answer: B, D
Explanation: A) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives four times a day is exhibiting behavior that indicates interventions have not been successful.
) Which nursing interventions would be appropriate for a client demonstrating extreme anxiety related to posttraumatic stress disorder (PTSD)? Select all that apply.
A) Encourage the client to discuss what caused the syndrome to develop.
B) Provide a calm, quiet environment.
C) Give the client paperwork to complete while waiting to be assessed.
D) Ask the client what is causing the anxiety.
E) Reassure the client that the environment is safe.
Answer: B, E
Explanation: A) The client diagnosed with PTSD who is exhibiting extreme anxiety needs immediate pharmacologic intervention, a quiet and calm environment, and reassurance of his or her safety. The client should not be given paperwork to complete. Asking the client what is causing the anxiety and encouraging the client to discuss what caused the syndrome to develop are not effective interventions for acute anxiety related to this disorder and should not be done.
A client is admitted with a diagnosis of posttraumatic stress disorder (PTSD). During a review of the client's history, the nurse is made aware that the client suffers from depression and suicidal thoughts. While interviewing the client, the client tells the nurse he is feeling extremely irritable and that the main reason he is there is because he has been having frequent nightmares. Based on the assessment findings, which medication prescription does the nurse anticipate for this client? A) Propranolol (Inderal) B) Prazosin (Minipress) C) Risperidone (Risperdal) D) Fluvoxamine (Luvox)
Answer: B
Explanation: A) Prazosin is an antihypertensive medication that may be prescribed for treatment and prevention of nightmares. Propranolol (Inderal) is a beta-blocker; its possible uses include management of anxiety states and prevention of acute panic states. Risperidone (Risperdal) is an antipsychotic that may be used in the treatment of obsessive-compulsive disorder (OCD) or panic disorders. Fluvoxamine (Luvox) is a selective serotonin reuptake inhibitor (SSRI) that may be used in the treatment of OCD.
A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD). The client was recently admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority goal to include in the client’s plan of care?
A) The client will report a reduction in or cessation of nightmares.
B) The client will report a decreased perception of anxiety.
C) The client will discuss emotions related to traumatic experiences.
D) The client will remain free from injury or harm.
Answer: D
Explanation: A) Ensuring that the client remains free of injury would be the priority goal. The client was admitted with thoughts of suicide, and this places the client at risk for harm or self-injury. Safety is a priority. The other goals are relevant to the care of the client; however, they are not the priority goals.
A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD) who was admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority nursing diagnosis for this client? A) Disturbed Sleep Pattern B) Post-Trauma Syndrome C) Risk for Other-Directed Violence D) Risk for Self-Directed Violence
Answer: D
Explanation: A) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore, Risk for Other-Directed Violence would not be appropriate for this client.
Which individual has the highest risk of developing PTSD? A) Victim of assault B) Natural disaster survivor C) Motor vehicle crash survivor D) Military veteran
Answer: D
Explanation: A) Although all of these individuals may develop PTSD, the incidence of PTSD is particularly high among military personnel who have been deployed in overseas combat.
Which form of therapy might be used to help an individual with posttraumatic stress disorder (PTSD) visit the location where a traumatic event occurred? A) Cognitive-behavioral therapy B) Dual attention stimulus therapy C) EMDR therapy D) Exposure therapy
Answer: D
Explanation: A) Exposure therapy assists the patient by gradually exposing them to elements of the traumatic event using writing, pictures, and visiting the place where the traumatic event occurred. Cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and dual attention stimulus are all forms of therapy that might be used to help treat an individual with PTSD, but these types of therapy do not involve visiting the location where the traumatic event occurred.
) The nurse is assessing a 4-year-old child. Which assessment finding indicates to the nurse that the child might have suffered a traumatic event?
A) The child refuses to talk or answer questions when previously the child chatted constantly.
B) The child draws pictures of family when previously the child drew pictures of animals.
C) The child complains of a stomachache and has a fever.
D) The child plays quietly in a corner when previously the child sat on his mother’s lap.
Answer: A
Explanation: A) Forgetting how to talk or not talking at all are signs of posttraumatic stress disorder (PTSD) in children under the age of 6. A child with PTSD may draw pictures that symbolize the trauma, not simple pictures of family or animals. Somatic complaints are more common in older adults with PTSD and likely indicate conditions other than PTSD in young children. Children with PTSD may behave recklessly or aggressively, not play quietly.
The nurse is assessing two clients: a 23-year-old man who recently returned from overseas deployment with the military and a 68-year-old man who served in the military during the Vietnam War. Both clients have been diagnosed with posttraumatic stress disorder (PTSD). Which statement did the nurse likely record from the 68-year-old man?
A) “I startle at every sudden noise I hear, whether it is loud or quiet.”
B) “I haven’t had much of an appetite lately, and I keep forgetting important things.”
C) “I just want to go out and hit someone.”
D) “I feel so guilty that I came home and three of my good buddies didn’t.”
Answer: B
Explanation: A) Older veterans may report more somatic complaints, such as loss of appetite, sleep disturbances, and cognitive problems, than younger veterans with PTSD. Older veterans are also less likely to have typical PTSD symptoms such as an exaggerated startle response and exhibit less depression, hostility, and guilt than younger veterans with PTSD.
) The nurse is caring for a victim of rape. Which interventions should the nurse include in the client’s plan of care? Select all that apply.
A) Notifying an attorney for the client
B) Supporting the victim during the examination
C) Identifying the individual who committed the rape
D) Treating acute injuries
E) Providing referrals for follow-up care
Answer: B, D, E
Explanation: A) Priorities of nursing care include treating any acute injuries, supporting the victim during the examination, and providing referrals for follow-up care. Nursing priorities do not include identifying the individual who committed the rape or notifying an attorney for the client.
A client, who was raped and refuses to see any male healthcare providers, tells the nurse that she had an "incident" that she does not want to talk about, and wants a bed by the door. Which nursing diagnosis is appropriate for the client? A) Relocation Stress Syndrome B) Readiness for Enhanced Power C) Rape-Trauma Syndrome D) Acute Confusion
Answer: C
Explanation: A) Rape-Trauma Syndrome can manifest itself in many ways depending on the client. Some clients, such as this one, exhibit fear, especially of individuals of the same gender as the attacker. Clients may also exhibit humiliation, shame, and distrust in others. This client is not displaying evidence of readiness for enhanced power. There is no evidence that the client is experiencing relocation stress syndrome or acute confusion.
) The nurse is providing care for a client who was the victim of sexual abuse 8 months ago. Which ongoing, long-term treatment goals are appropriate? Select all that apply.
A) The client’s symptoms of anxiety and fear will decrease.
B) The client will involve significant others in the treatment plan.
C) The client will be able to verbalize legal rights.
D) The client will establish rapport and build a trusting nurse—client relationship.
E) The client will learn how to reconnect with others.
Answer: A, E
Explanation: A) Decreasing symptoms of anxiety and fear and learning how to reconnect with others may take months or years, whereas the other treatment goals can be met in the short term (hours to days). The nurse should have involved significant others in the treatment plan, established rapport, and made the client aware of legal rights immediately after the sexual abuse occurred.
A client recovering from a rape tells the nurse that flashbacks do occur but can be managed. Which techniques should the nurse suggest to the client for managing flashbacks about the event? Select all that apply. A) Restoring personal choice B) Deep breathing C) Muscle relaxation D) Problem solving E) Guided imagery
Answer: B, C, E
Explanation: A) Techniques that the client can use to control flashbacks include muscle relaxation, deep breathing, and guided imagery. Problem solving and restoring personal choice are techniques to support coping behaviors.
A client who was raped tells the nurse that she must not get pregnant. Which response by the nurse is appropriate?
A) “The baby could always be given up for adoption.”
B) “You will not know for sure for at least a few more days.”
C) “Emergency contraception is available to prevent pregnancy.”
D) “Are you sure the rapist did not use a condom?”
Answer: C
Explanation: A) Female rape victims may request information about emergency contraception if the attacker did not use a condom. The nurse should not tell the client that it will be a few more days to know for sure if she is pregnant. The nurse should not question whether the rapist used a condom. The client does not want to get pregnant. The nurse should not talk about giving a baby up for adoption at this time.
The nurse working in the emergency department is aware that rape victims initially exhibit which emotions? Select all that apply. A) Shock B) Disbelief C) Anger D) Self-blame E) Humiliation
Answer: A, B
Explanation: A) Initial responses to rape generally include feelings of shock and disbelief. Anger, humiliation, and self-blame are early responses but not typically the initial response.
A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted syphilis. Which prescription does the nurse anticipate for this client? A) Penicillin B) Ceftriaxone and azithromycin C) Tinidazole D) Doxycycline
Answer: A
Explanation: A) Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and either azithromycin or doxycycline. Trichomoniasis is treated with tinidazole or metronidazole. Chlamydia is treated with doxycycline.
A rape victim is being seen in the clinic. Upon assessment it is discovered the client has contracted trichomoniasis. Which prescription does the nurse anticipate for this client? A) Penicillin B) Ceftriaxone and azithromycin C) Metronidazole D) Doxycycline
Answer: C
Explanation: A) Trichomoniasis is treated with metronidazole or tinidazole. Syphilis is treated with penicillin. Gonorrhea is treated with a combination of ceftriaxone and azithromycin. Chlamydia is treated with doxycycline.
Which type of rape often involves the use of date rape drugs? A) Acquaintance rape B) Marital rape C) Anal rape D) Gang rape
Answer: A
Explanation: A) The most common type of rape that uses date rape drugs is acquaintance rape, which is rape committed by an acquaintance or other familiar individual. Although the other types of rape may involve date rape drugs, this is far less common than for acquaintance rape.
The nurse is caring for a client who has a history of being physically and sexually abused as a child, and his father abandoned the family when he was 7 years old. The nurse recognizes that this increases the client's risk of becoming a perpetrator of rape because of which type of risk factors? A) Individual B) Relationship C) Community D) Societal
Explanation: A) Relationship risk factors for perpetration include a family environment characterized by physical violence and conflict; a childhood history of physical, sexual, or emotional abuse; and poor parent-child relationships, particularly with fathers. Although the client may also have individual, community, or societal risk factors as well, the factors the nurse has identified here are relationship risk factors.
A 72-year-old male client has been admitted to the emergency department after a nurse at the long-term care facility where the client lives found the client bleeding from his rectum. The client told the emergency department nurse that one of the caregivers at the facility raped him. What intervention will the nurse need to include in this client’s plan of care before discharge?
A) Help the client find a new long-term care facility.
B) Help the client create a post-discharge safety plan.
C) Help the client find a lawyer to sue the long-term care facility.
D) Help the client understand the warning signs of suicide.
A 72-year-old male client has been admitted to the emergency department after a nurse at the long-term care facility where the client lives found the client bleeding from his rectum. The client told the emergency department nurse that one of the caregivers at the facility raped him. What intervention will the nurse need to include in this client’s plan of care before discharge?
A) Help the client find a new long-term care facility.
B) Help the client create a post-discharge safety plan.
C) Help the client find a lawyer to sue the long-term care facility.
D) Help the client understand the warning signs of suicide.
The nurse is preparing to teach a class about date rape to a group of college-age students. When discussing date rape drugs, which method of prevention should the nurse include in her presentation?
A) Never leave a location with a friend.
B) Only accept premade drinks from someone you know.
C) Never leave your drink unattended.
D) Only consume drinks handed to you directly by the bartender or a waitress.
Answer: C
Explanation: A) The nurse should include several methods of prevention in her presentation, including the instruction to never leave your drink unattended. Individuals are often given date rape drugs by acquaintances, so accepting premade drinks even from an acquaintance may not be safe. Individuals should watch their drink being made by the bartender rather than trusting that all drinks coming directly from a bartender or waitress are safe. Individuals may leave a location with a friend that they explicitly trust even if they feel they have been drugged.
A nurse is preparing to discharge a client who experienced a myocardial infarction. The client will have to make many lifestyle changes, and the nurse is providing instruction on how to implement a heart-healthy lifestyle. Which is the best description of the client education the nurse is presenting to this client?
A) Dependent function of nursing that needs a healthcare provider’s order to implement
B) Important independent nursing function
C) Activity nurses begin to learn after training on the job
D) Way to establish the client’s dependence on the nurse
A nurse is preparing to discharge a client who experienced a myocardial infarction. The client will have to make many lifestyle changes, and the nurse is providing instruction on how to implement a heart-healthy lifestyle. Which is the best description of the client education the nurse is presenting to this client?
A) Dependent function of nursing that needs a healthcare provider’s order to implement
B) Important independent nursing function
C) Activity nurses begin to learn after training on the job
D) Way to establish the client’s dependence on the nurse
The nurse is caring for an adult client who has been diagnosed with high cholesterol. Which is important for the nurse to consider when teaching this adult client?
A) Adults are more oriented to learning when the material is useful immediately.
B) Adults are more likely to adhere to a regimen than are children.
C) Adults usually can find information on their own.
D) Adults do not need to be evaluated for understanding as children do.
Answer: A
Explanation: A) When teaching a client, the nurse considers that most people learn and retain information if the information is immediately useful. Some clients can find information on their own; however, not all information that the client can find is factual, and clients should be taught how to discern the difference between trustworthy information and unreliable and potentially dangerous information. All clients need to be evaluated to ensure that the right information was retained. Adults will not necessarily adhere to a regimen more than children will. Effective teaching and the client’s readiness to learn help with adherence.
Which theory of learning holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations? A) Constructivist B) Behaviorist C) Social learning D) Cognitive
Which theory of learning holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations?
A) Constructivist
B) Behaviorist
C) Social learning
D) CognitiveAnswer: A
Explanation: A) Constructivist theory holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations. In behaviorist theory, learning is thought to occur when an individual’s response to a stimulus is either positively or negatively reinforced. In social learning theory, learning primarily results from instruction and observation. In cognitive learning theory, learning involves the processes of acquiring,
A nurse is working in a neonatal intensive care unit (NICU). The nurse wants to teach a mother of a premature baby how to give her baby a bath. Which statement by the mother reflects a readiness to learn?
A) “You’ll give us written instructions before we go home, correct?”
B) “When my baby is just a little bigger, I’ll feel more comfortable giving him a bath.”
C) “I want to make sure my husband is here, in case I don’t hear everything that’s said.”
D) “I’m so afraid I’ll hurt my baby with all these tubes and wires.”
Answer: C
Explanation: A) Readiness to learn is the demonstration of behaviors or cues that reflect a learner’s motivation, desire, and ability to learn at a specific time. The client who wants her husband involved is demonstrating motivation and willingness to learn. Statements about fear of the situation need to be addressed so that the fear will not inhibit the learning process. Wanting to wait until discharge or at least until the baby is older reflects uncertainty and possibly fear and should be addressed before learning can occur.
A nursing student has been assigned to present a teaching project to the class, using each of Bloom’s taxonomy domains. The student has planned several activities to include when presenting the project to the class. Which activities are within the affective domain? Select all that apply.
A) Class members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class.
B) Class members must list the technical skills they have learned.
C) Class members must demonstrate a favorite nursing skill for the class.
D) Class members must reflect on how they felt the first time they provided direct client care.
E) Class members must identify two attitudinal changes that have occurred in their lives since beginning their nursing education.
Answer: D, E
Explanation: A) In cognitive theory, learning occurs across three primary domains: cognitive, or “thinking”; affective, or “feeling”; and psychomotor, or “skill.” The affective domain includes emotional responses to tasks, such as feelings, emotions, interests, attitudes, and appreciations. Listing technical skills and reading or summarizing information is part of the cognitive domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation. The psychomotor domain includes hands-on motor skills, such as demonstration.
A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn?
A) A client who has been there the longest and is a great “coach” for newcomers
B) A client who has been struggling with following nursing directives regarding discharge goals
C) A client who is excited to learn ambulation techniques
D) The client who has just moved in and is already eager for discharge
Answer: C
Explanation: A) Motivation is the desire to learn and influences how quickly and to what extent an individual learns. It is generally greatest when an individual recognizes a need and believes the need will be met through learning. The client who is excited to learn about ambulation techniques understands that learning about it will help take his recovery to a high level.
The nurse educator is preparing to teach a group of nursing students how to navigate the internet to research healthcare information. Which does the educator plan to include during lecture?
A) A directory of campus internet sites of interest
B) How to search for and evaluate health information
C) A directory of libraries
D) Information technology instruction
Answer: B
Explanation: A) Campus health centers that use the internet as a tool for health education must train nursing students regarding how to search for and evaluate the health information they find. Sites of interest for the campus would not directly impact the nursing program. Information technology is a subject that teaches nurses how to use technology for the delivery of care and communication. Libraries are important, but knowing about them would not be a part of this presentation.
