MOD 1 Flashcards by Bri Mikayla

An older-adult client who is having difficulty breathing is admitted to the hospital. Which of the following approaches is the best for the nurse to use to obtain a complete health history?

Schedule several short sessions with the client to gather subjective data.

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Immediate surgery is planned for a client with acute abdominal pain. Which of the following questions will elicit the most complete information about the client’s coping-stress tolerance pattern?

“Are there other major problems that are a concern right now?”

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During the health history interview, a client tells the nurse about periodic fainting spells. Which question by the nurse will be most helpful in determining the setting in which the fainting spells occur?

“Where are you when you have the fainting spells?”

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The nurse records the following general survey of a client: “The client is a 68-year-old male Asian accompanied by his wife and two daughters. Alert and oriented. Does not make eye
contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” Which of the following information should be added to this general survey documentation?

Nutritional status

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A nurse is performing a health history and physical examination for a client with right-sided rib fractures. Which of the following data is a pertinent negative finding?

Client denies having pain when the area over the fractures is palpated.

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As the nurse assesses the client’s neck, the client says, “My neck is so stiff I can hardly move it.” This client statement indicates the nurse should perform which of the following assessments?

Focased

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The nurse is preparing to perform a focused abdominal assessment for a client who has high-pitched bowel sounds. Which equipment will be needed?

Stethoscope

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When the nurse is planning for the physical examination of an alert older-adult client, which of the following adaptations to the examination technique should be considered?

Organizing the sequence to minimize position changes.

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While the nurse is taking the health history, a client states, “My father and grandfather both had heart attacks and were unable to be very active afterwards.” This statement reflects which of the following functional health patterns?

Health perception–health management

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A client is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time?

Emergency

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The nurse records the following general survey of a client: “The client is a 68-year-old Indigenous male accompanied by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” Which of the following areas does the nurse need to
assess to complete the general survey?

Body movements

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When assessing the circulation to the lower leg of a client who has had knee surgery, which action should the nurse take first?

Visually inspect the colour of the foot.

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When assessing a client’s abdomen during the admission assessment, which of these actions should the nurse take first?

Listen to the bowel sounds.

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When admitting a client who has just arrived on the medical unit with severe abdominal pain, what should the nurse do first?

Take the initial vital signs and then deal with the abdominal pain before completing the health history.

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The nurse is assessing a client the morning of the first postoperative day and notes redness and warmth around the incision. Which of the following actions should the nurse implement?

Document the assessment.

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A client with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the following actions is priority as a result of this assessment data?

Obtain wound cultures.

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The nurse is caring for a client with a systemic bacterial infection that has “goose pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, which of the following
assessments should the nurse monitor?

Rising body temperature

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The nurse is caring for a young adult client who is receiving antibiotics for an infected leg
wound and has a temperature of 38.8°C (101.8°F). Which of the following actions by the nurse is most appropriate?

Check the client’s oral temperature again in 4 hours.

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A client’s 6 ́ 3 cm leg wound has a 2 mm black area surrounded by yellow-green semiliquid material. Which of the following dressings should the nurse use for wound care?

Hydrocolloid dressing (DuoDerm)

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The nurse is caring for a client who has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. Which of the following terms should the nurse use to document these findings?

Yellow wound

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Which of the following nursing actions is most likely to detect early signs of infection in a client who is taking immuno-suppressive medications?

Ask about fatigue or feelings of malaise.

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The nurse is planning care for a client and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for using this type of dressing?

Wound with purulent drainage and dry brown areas

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A client is admitted to the hospital with a pressure injury on the left buttock. The nurse notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure injury wound stages should the nurse document?

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A client who is confined to bed and who has a stage 2 pressure injury is being cared for in the home by family members. To prevent further tissue damage, which of the following actions
should the nurse instruct the family members that it is most important?

Change the client’s position every 2 hours.

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Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a client who has a stage III sacral pressure injury?

Administer the ordered PRN oral opioid 30 minutes before the dressing change.

The charge nurse observes a new graduate performing a dressing change on a client with a stage 2 left heel pressure injury. Which of the following actions by the new graduate indicates a need for further education about pressure injury care?

Cleans the injury with a sterile dressing soaked in half-strength hydrogen peroxide.

A client arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which of the following actions by the nurse is most appropriate?

Elevate the ankle above heart level.

The nurse is admitting a client with stage 3 pressure injuries on both heels. Which of the following information obtained by the nurse will have the most impact on wound healing?

The client takes corticosteroids daily for rheumatoid arthritis.

The nurse has just received change-of-shift report about the following four r. Which client will the nurse assess first?

The client who has been receiving immunosuppressant medications and has a temperature of 38.9°C (102°F).

During wound healing, a wound is resistant to infection during which of the following phases?

Granulation phase

The nurse is caring for a client with diabetes who had abdominal surgery one week ago, and obtains the following data. Which of these findings should be reported immediately to the health care provider?

New 5-cm separation of the proximal wound edges

The nurse is caring for a client with diabetes who has been admitted for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, which of the following actions is priority?

Maintaining the client’s blood glucose within a normal range

The nurse is caring for an adult client with stage 3 pressure injuries on both heels who has been in hospital for 6 days. Which of the following timeframes for wound assessment is accurate when a client is in the acute care setting?

Every 24 hours

A client’s temperature has been 38.8°C (101.8°F) for several days. The client’s normal caloric intake to meet nutritional needs is 2 000 calories per day. Knowing that the metabolic rate increases 13% for every 1°C (33.8°F) increase in temperature above 37.8°C (100°F) in body temperature, calculate the total calories the client should receive each day.

2 260

The nurse is teaching a client about routine glaucoma testing. Which of the following information should the nurse include in the teaching plan?

Application of a Tono-pen to the surface of the eye will be needed.

Which assessment information obtained by the nurse when performing an eye examination for an older-adult client indicates that more extensive examination of the eyes is needed?

The client complains of persistent photophobia.

The nurse is performing an eye examination on a client and is assessing for accommodation. Which of the following actions should the nurse implement?

Observe the pupils when the client focuses on a close object and then on a distant object.

The nurse is delivering a health-promotion session at the eye clinic and advises all clients to wear sunglasses that protect the eyes from ultraviolet light. Which of the following conditions is associated with ultraviolet sunlight exposure?

Cataracts

The nurse’s assessment of a client’s visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 40 feet and the right eye can see at 20 feet what a person with normal vision can see at 50 feet. Which of the following findings should the nurse document?

Left eye 20/40; right eye 20/50

The nurse is conducting a vision assessment on a client and is assessing the client’s visual field. Which of the following actions should the nurse include?

Have the client cover one eye while facing the nurse.

The nurse is observing a student who is preparing to perform an ear examination of an adult client. Which of the following actions by the student should cause the nurse to intervene in the assessment?

Pulls the auricle of the ear down and backward

The nurse is obtaining a health history from a middle-aged adult client. Which of the following client statements is most important to communicate to the health care provider?

"The peripheral part of my vision is decreased.”

The nurse is obtaining a health history from an older-adult client, who is new to the eye clinic and who has glaucoma. Which of the following information given by the client will have the most implications for the client’s treatment?

“I take metoprolol daily for angina.”

The nurse is preparing to assess the visual acuity for a client in the outpatient clinic. Which of the following supplies should the nurse obtain to prepare for this assessment?

Snellen chart

The nurse is admitting a client to the hospital who has an eye patch in place and tells the nurse “I had a recent eye injury, so I need to wear this patch for a few weeks.” Which of the following nursing diagnoses will the nurse include in the plan of care?

Risk for falls as evidenced by impaired vision (decrease in stereoscopic vision)

The nurse is preparing a client in the eye clinic for refractometry. Which of the following information should the nurse include in client teaching?

“You will need to wear sunglasses for a few hours after the exam.”

The nurse is assessing an older-adult client for the presence of presbyopia. Which of the following equipment will the nurse need to obtain before the examination?

Jaeger chart

The nurse is caring for a client in the emergency department with symptoms of eye itching and pain caused by sleeping with contact lenses in place. Which of the following equipment should the nurse anticipate preparing to facilitate further examination of the client’s eye?

Fluorescein dye

The nurse is obtaining a nursing history from a client when the client indicates symptoms of dizziness when bending over and nausea and dizziness associated with physical activities. Which of the following topics should the nurse include in this client’s teaching plan?

Rotary chair testing

The nurse is taking a health history of a new client at the ear clinic and the client states, “I always sleep with the radio on.” Which of the following questions is most appropriate to obtain more information about possible hearing problems? “

“Have you noticed any ringing in your ears?”

The nurse is admitting a client to the hospital preoperatively. Which of the following findings may indicate that the client is at risk for falls while hospitalized?

Nystagmus when head is turned rapidly

The nurse is conducting a health history with a new client in the outpatient clinic. Which of the following medications in the health history may indicate the need to perform a focused hearing assessment?

Ibuprofen for 20 years to treat arthritis

Which of the following actions should the nurse include in the plan of care for a client who has vestibular disease?

Monitor the client’s ability to ambulate safely.

The nurse in the eye clinic is examining an older-adult client who says “I see small spots that move around in front of my eyes.” Which of the following actions should the nurse take first?

The tympanum is bluish-tinged.

The nurse is assessing a client in the outpatient eye clinic who has myopia and presbyopia. Which of the following assessments should the nurse implement to evaluate the effectiveness of the prescribed bifocals?

Both near and distant vision

A client is seen in the ophthalmology clinic and diagnosed with recurrent staphylococcal and seborrheic blepharitis. Which of the following topics should the nurse include in the teaching plan?

Using baby shampoo to clean the lids

Which of the following actions should the nurse take when assisting a totally blind client to walk to the bathroom?

Walk slightly ahead of the client and allow the client to hold the nurse’s elbow.

A client has been seen at a clinic for repeated hordeolum of the eyes during the last 6 months. Which of the following actions should the nurse recommend to the client to help prevent further infection?

Discard all open or used cosmetics used near the eyes.

Which of the following topics should the nurse plan to include when teaching the client with herpes simplex keratitis of the left eye about management of the infection?

Need for frequent handwashing and avoiding touching the eyes

The nurse is caring for a client in the eye clinic who has 20/200 vision with the use of corrective lenses. Which of the following information should the nurse include when providing client teaching

Where to obtain specialized magnifiers

The nurse is caring for a client with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which of these actions should be included in the plan of care?

Discussing the need for sexually transmitted infection testing

Which of the following topics will the nurse include in client teaching following outpatient cataract surgery and lens implantation?

Administration of antibiotic eye drops

The nurse is reviewing a client’s medical record and notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. Which of the following parameters should the nurse assess?

Peripheral vision

The nurse is caring for a client with a left retinal detachment who had a pneumatic retinopexy procedure. Which of the following information should be included in the discharge teaching plan?

The purpose of maintaining the head in a prescribed position for several weeks

The nurse is caring for a client with age-related macular degeneration who has just had photodynamic therapy. Which of the following statements by the client indicates that the discharge teaching has been effective?

“I will keep covered with long-sleeved shirts and pants for the next 5 days.”

The nurse is assessing a client with primary open-angle glaucoma (POAG) to evaluate if the treatment has been effective. Which of the following parameters should the nurse assess to determine if there has been improvement?

Visual field

A client with glaucoma who has been using timolol drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. Which of the following responses by the nurse is most appropriate?

“The drops are uncomfortable, but it is very important for you to use them as prescribed to retain your vision.”

The nurse is admitting a client to the hospital with severe COPD and a history of glaucoma. Which of the following prescribed medications should the nurse question?

Levobunolol 0.5% eye drops

The nurse is caring for a client who has bacterial endophthalmitis in the left eye, is restless, frequently asking whether the eye is healing and whether removal of the eye will be necessary. Based on the assessment data, which of the following nursing diagnoses is appropriate?

Anxiety related to threat to current status (uncertainty of outcome of treatment)

To decrease the risk for future hearing loss, which of the following actions should the nurse working with college students at the on-campus health clinic implement?

Discuss the importance of limiting exposure to very high amplified music.

To decrease the risk for future hearing loss, which of the following actions should the nurse working with college students at the on-campus health clinic implement?

Discuss the importance of limiting exposure to very high amplified music.

A client with external otitis has an ear wick placed and a new prescription for antibiotic otic drops. After the nurse provides client teaching, which of the following client statements indicates that more instruction is needed?

“I should clean my ear canal daily with a cotton-tipped applicator.”

The nurse is preparing a client with chronic otitis media for a tympanoplasty. Which of the following information should the nurse include in preoperative teaching related to postoperative expectations?

Avoidance of coughing or blowing the nose

The nurse is assessing a client who has recently been treated with amoxicillin for acute otitis media of the right ear. Which of the following assessment data obtained by the nurse is of most concern?

The client has a temperature of 38.1°C (100.6°F).

The nurse is admitting a client with Ménière’s disease who has vertigo, nausea, and vomiting. Which of the following nursing interventions should be included in the care plan?

Keep the client’s room darkened.

The home health nurse observes a client taking these actions when self-administering eardrops. Which of the following client actions indicates a need for more teaching?

The client gets the eardrops out of the refrigerator just before administering the drops.

The nurse is admitting an older-adult client and the client repeatedly asks the nurse to “speak up so that I can hear you.” Which of the following actions should the nurse take?

Speak normally but more slowly.

An older-adult client with presbycusis is fitted with binaural hearing aids. Which of the following information should the nurse include when teaching the client how to use the hearing aids?

Experiment with volume and hearing ability in a quiet environment initially.

A client with hearing loss asks the nurse about the use of a cochlear implant. Which of the following information will the nurse include when replying to the client?

Cochlear implants require training in order to receive the full benefit.

Which of the following interventions should the nurse implement for a client who has just been diagnosed with viral conjunctivitis?

Demonstrate appropriate handwashing technique.

Which of the following information should the nurse include when teaching a client with keratitis caused by herpes simplex type 1?

Importance of taking all of the ordered oral acyclovir

The nurse is admitting a client to the outpatient surgery unit who is scheduled for cataract extraction and implantation of an intraocular lens. Which of the following information has the most immediate implications for the client’s care?

The client takes three antihypertensive medications.

The nurse is caring for a client with neural presbycusis. Which of the following hearing changes should the nurse expect with this type of presbycusis?

Loss of speech discrimination

The nurse is admitting a client for surgery who has functional blindness for several years and is cared for by the client’s spouse. Which of the following actions is most important to implement during the initial assessment?

Make eye contact with the client and ask about any need for assistance.

Which of the following actions is an example of an approach magnification?

Sitting closer to a television while watching it

The camp nurse is caring for a client who is complaining of bilateral eye pain after a campfire log exploded, sending sparks into the client’s eyes. Which of the following actions should the nurse take first?

Cover the eyes with dry sterile patches and protective eye shields.

The nurse is caring for a client with an acute attack of Ménière’s disease. Which of the following actions carried out by a family member that is visiting the client should the nurse intervene?

Turns on the client’s television

A client who had cataract extraction and intraocular lens implantation the previous day calls the eye clinic and gives the nurse all of this information. Which of the following information is the priority to communicate to the health care provider?

The client has eye pain rated at a 5 (on a 0–10 scale).

Which of the following assessment findings in a client who was struck in the right eye with a baseball is a priority for the nurse to communicate to the health care provider in the emergency department?

The client complains of “a curtain” blocking part of the visual field.

The charge nurse observes a newly hired nurse caring for a client who has just arrived in the postanaesthesia care unit after having right cataract removal and an intraocular lens implant. Which of the following interventions requires that the charge nurse intervene?

The nurse encourages the client to cough.

The nurse is assessing the presence or absence of contact lenses in an unconscious client. Which of the following directions should the nurse shine a pen light?

Obliquely into the eye

The nurse is admitting a client with a head injury after a motor vehicle accident who has shortness of breath and severe eye pain. Which of the following actions should the nurse take first?

Check the client’s oxygen saturation.

These medications are prescribed by the health care provider for a client who has just been admitted to hospital with acute angle-closure glaucoma. Which of the following medications should the nurse give first?

Mannitol 100 mg intravenously

Which of the following nursing diagnoses is priority when caring for a client who is experiencing an acute attack of Ménière’s disease?

Risk for falls as evidenced by impaired balance

The nurse is caring for a client who had a stapedotomy yesterday. Which of the following findings is most important for the nurse to communicate to the health care provider?

The client’s oral temperature is 38.1°C (100.6°F).

Which assessment information documented in a client’s chart indicates that the nurse may need to continue to monitor the skin condition of an 82-year-old client admitted with bacterial pneumonia?

“Skin moist and intact, states history of allergic rashes”

The nurse is caring for a client who has a circular, flat, reddened lesion about 5 cm in diameter on his ankle. Which of the following actions would the nurse implement to determine whether the lesion is related to blood vessel dilation?

Press firmly on the lesion

The nurse is preparing for a teaching session with older-adult clients. Which of the following changes is an age-related change in the hair?

Decreased oils

The nurse is caring for a client who is dark-skinned and has been admitted to the hospital in severe respiratory distress. Which of the following actions should the nurse implement to determine whether the client is cyanotic?

Check the lips and oral mucous membranes.

A client asks the nurse why a potassium hydroxide test needs to be done. The nurse’s response is based upon the knowledge that which of the following is the purpose of this test?

Assess for fungal infection.

The nurse is caring for a client who has several angiomas on their legs. Which of the following actions should the nurse take next?

Assess the client for evidence of liver disease.

The nurse is caring for a client in the dermatology clinic who is scheduled for removal of a 15-mm multicoloured and irregular mole from the upper back. Which of the following biopsies would the nurse teach to this client?

Incisional

The nurse is conducting an assessment of the client’s skin and observes a ring of small, raised, discrete lesions filled with serous fluid on the client’s right temple. Which of the following descriptions would the nurse use when documenting the lesions?

Grouped

The nurse is caring for a client who reports chronic itching of the ankles and cannot keep from continuously scratching them. The nurse will plan to implement interventions to decrease the risk for which of the following conditions?

Lichenification

The nurse is admitted an older-adult client to an assisted-living facility and notes abnormalities on the skin. Which of the following abnormalities is the priority to discuss immediately with the health care provider?

Petechiae present on the chest and abdomen

To decrease the risk for sun damage to the skin, which information should the nurse include when teaching clients?

Try to stay out of the sun between the hours of 1 000 and 1 600.

The nurse is caring for a client with a urinary tract infection and has been prescribed ciprofloxacin. Which of the following information should the nurse include when teaching this client?

Use a sunscreen with a high SPF when exposed to the sun.

The nurse is caring for a client who has basal cell carcinoma (BCC) of the face. Which of the following information should the nurse include when teaching this client?

Minimizing sun exposure will reduce risk for future BCC.

The nurse is caring for a client in the dermatology clinic who has a small, slow-growing papule with ulceration and a depression in the centre of the lesion on the right cheek. Which of the following nursing interventions will the nurse anticipate performing for this client?

Prepare the client for a biopsy.

After the nurse determines that a client has the following risk factors for melanoma, which risk factor should be the focus of client teaching related to prevention?

The client uses a tanning booth throughout the winter.

The health care provider diagnoses impetigo for a client who has crusty vesicopustular lesions on the lower face. Which of the following topics would the nurse include in the teaching plan for this client?

How to clean the infected areas with soap and water

The nurse is teaching the client how to use wet compresses at home for treatment of poison ivy. Which of the following instructions would the nurse include in the teaching plan?

The material for the compress is to be 4–8 layers thick.

The nurse is assessing a client’s scalp and suspects the presence of pediculosis when which of the following assessment findings are observed?

Papular, wheal-like lesions with white deposits on the hair shaft

The health care provider prescribes topical 5-fluorouracil (5-FU) for a client with actinic keratosis on the nose. Which of the following information would the nurse include in the client teaching plan?

The nose will develop painful, eroded areas that will take weeks before completely healing.

A client with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. Which of the findings by the nurse indicates a possible adverse effect of the medication?

Thinning of the affected skin

The nurse is caring for a client who is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. Which of the following actions would the nurse plan to implement to minimize complications from this procedure?

Have the client use protective eyewear while receiving PUVA.

A client with an enlarging, irregular mole that is 6 mm in diameter is scheduled for outpatient treatment. Which of the following procedures would the nurse include in the teaching plan for this client?

Surgical excision

Which of the following information would the nurse include when teaching an older-adult client about skin care?

Use warm water and a moisturizing soap when bathing.

Which of the following actions would the nurse take when applying a wet dressing to an inflamed and pruritic area of skin on a client’s ankle?

Use a cool solution to wet the dressing.

The nurse is caring for a client who has just received a diagnosis of a fungal infection and the client asks the nurse how this will be treated. The nurses’ response is based upon knowledge that which of the following bases is the most common for antifungal treatment?

Powder

The nurse notes darker skin pigmentation in the skin folds of a client who has a body mass index of 40 kg/m2. Which of the following topics would the nurse include in client teaching?

Teach the client about the risk for type 2 diabetes.

The nurse is assessing a new client at the outpatient clinic and notes dry, scaly skin; thin hair; and thick, brittle nails. Which of the following actions is best for the nurse to take at this time?

Consult with the health care provider about the need for further diagnostic testing.

The nurse is providing care to a client with a squamous cell carcinoma (SCC) that had a Mohs procedure in the dermatology clinic. Which of the following nursing actions would be included in the postoperative plan of care?

Educate about use of cold packs to reduce bruising and swelling.

A client with atopic dermatitis has a new prescription for tacrolimus. After teaching the client about the medication, which statement by the client indicates that further teaching is needed?

“If the medication burns when I apply it, I will wipe it off and call the doctor.”

After the nurse has finished teaching a client about application of corticosteroid cream to an area of contact dermatitis on the right leg, which of the following client actions indicates that more teaching is needed?

The client applies a thick layer of the cream to the affected skin.

The nurse is teaching a client about the use of a wet dressing to reduce pruritus. Which of the following time frames would the nurse instruct the client to leave the dressing on for?

10–30 minutes

The nurse is assessing a client who has just arrived in the postanaesthesia recovery area (PACU) after a blepharoplasty. Which of the following assessment data is a priority?

The skin around the incision is pale and cold when palpated.

A client who has severe refractory psoriasis on the face, neck, and extremities has quit working and withdrawn from social activities because of the appearance of the lesions. Which of the following actions should the nurse take first?

Ask the client to describe the impact of psoriasis on quality of life.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:

Replaced every 4 weeks.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:

Contains sensory receptors.

The nurse is examining a patient who tells the nurse, “I sure sweat a lot, especially on my face and feet but it doesn’t have an odour.” The nurse knows that this condition could be related to:

Eccrine glands.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?

The newborn’s skin is more permeable than that of the adult.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

An increased loss of elastin and a decrease in subcutaneous fat

During the aging process, the hair can look grey or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

Melanocytes.

During an examination, the nurse finds that a patient has excessive dryness of the skin. When charting, the nurse describes this condition as:

Xerosis.

A 22-year-old woman comes to the clinic because of severe sunburn and states, “I was out in the sun for just a couple of minutes.” The nurse begins a medication review with her, paying special attention to which class of medications?

Tetracyclines for acne

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the health history interview, the patient informs the nurse that she takes an oral hypoglycemic medication for diabetes. The nurse provides teaching about the medication and:

Importance of sunscreen and avoiding direct sunlight.

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should inform her that acne:

Is caused by increased sebum production.

A 75-year-old woman with a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse encourages her to stop trying to remove the corn with scissors because:

Her actions could increase her risk for infection and lesions because of her chronic disease.

While assessing a patient’s skin, the nurse notes multiple skin fissures on the hands. The nurse recognizes this as:

Potential openings for bacterial infection.

A patient comes in for a physical examination and complains of “freezing to death” while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:

Peripheral vasoconstriction.

A 62-year-old patient with heart failure comes to the clinic for his annual examination. During skin assessment, the nurse notes slight swelling to the patient’s feet, and indentations which quickly fade when both feet are palpated. The nurse will chart this finding as:

Bilateral moderate pitting 2+ edema.

A patient is especially worried about the white coloration of an area of skin on her feet, and she has been told it is vitiligo. The nurse explains that vitiligo is

Caused by the complete absence of melanin pigment.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

Colour variation

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition results from hyperemia and knows that it can be caused by:

Excess blood in the dilated superficial capillaries.

During a skin assessment, the nurse initially is concerned that the patient who is of East Asian origin has skin that is yellowish-brown. On further assessment, the nurse notes that the skin on the hard and soft palate is pink and the patient’s sclerae are not yellow. From this finding, the nurse recognizes that the patient likely does not have:

Jaundice.

A patient of African origin is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient’s skin?

Ashen, grey, or dull

An older adult woman is brought to the emergency department after she was found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?

Dry mucous membranes and cracked lips

A 42-year-old woman is concerned about several small, slightly raised, bright red dots that have appeared on her chest. On examination, the nurse explains that the spots are probably:

Senile angiomas.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse notes:

Clubbing of the nails.

A newborn infant has Down’s syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant’s mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:

Cutis marmorata.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse will chart this finding as:

Chloasma.

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment, the nurse notices several areas of pigmentation that look greasy, dark, and “stuck on” his skin. The nurse informs the patient that they are:

Seborrheic keratoses, which do not become cancerous.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, “What causes these liver spots?” The nurse tells her, “They are:

“Clusters of melanocytes that appear after extensive sun exposure.”

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. The nurse documents this finding as a:

Papule.

From reviewing the patient’s medical record, the nurse notes that the patient has a lesion that is confluent in nature. During assessment, the nurse observes:

Lesions that run together.

A patient has had a “terrible itch” for several months and states that he has been continuously scratching it. During examination, the nurse finds:

Lichenification.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse replies, “The physician is referring to the:

“Merging extensive patch of red dots and larger bruises on the feet.”

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a red base and suspects:

Impetago

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth and that the lesions are raised approximately 1 to 3 mm. The nurse will assess the child for:

A red-purple, maculopapular, blotchy rash behind the ears and on the face.

The nurse is assessing the skin of a patient who has AIDS and notices multiple patchlike lesions on the temple and beard area that are faint pink in colour. The nurse recognizes these lesions as:

Kaposi’s sarcoma.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:

Tinea capitis.

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:

Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?

Severe dehydration

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in colour. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?

Heart failure

A 40-year-old woman reports a change in mole size, accompanied by colour changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:

Refer the patient for further assessment because of the risk for melanoma based on signs and symptoms.

The nurse is assessing a patient with emphysema for clubbing of the fingernails, which is confirmed by:

Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

The nurse is performing an assessment for jaundice in a patient who has liver disease. Which of these assessment findings is indicative of true jaundice?

Yellow coloration of the sclera that extends up to the iris

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best?

Palpating the skin for edema and increased warmth

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash consists of small, red, flat skin spots with a “bull’s eye” pattern across his midriff and behind his knees. The nurse suspects:

Lyme disease.

A 52-year-old woman has a small solid bump on her nose that has rounded, pearly borders and a central red ulcer. She states that she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?

Basal cell carcinoma

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the past 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration and tests skin mobility and turgor over the infant’s:

Abdomen.

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red colour. The nurse suspects that this colouring is caused by:

Carbon monoxide poisoning.

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient’s fingernails?

Pitting

The nurse is assessing a 50-year-old patient who is restricted to the bed. The patient has limited mobility and needs to be frequently repositioned. The nurse will use the Braden Scale to assess for:

Risk for developing pressure ulcers.

The nurse is performing a Braden Scale assessment on a 65-year-old bedbound patient with limited mobility. The patient is unable to communicate needs or discomfort but does respond to verbal commands. The nurse notes that the patient’s skin is moist and will likely require a linen change each shift. The patient is confined to the bed with no ability to walk and makes very limited changes to body extremities occasionally. The patient requires frequent repositioning with maximum assistance. The patient eats about half of the food offered. The nurse charts the findings as:

High Risk for developing pressure ulcers.

The nurse initiates a Braden Scale assessment of the 85-year-old patient who is independent with activities of daily living and frequently ambulates around the unit. The patient scores a 23 which the nurse documents as:

No risk for pressure ulcer development.

When examining the patient’s eyes, the nurse notices that his eyelid margins approximate completely when closed. The nurse will:

Document this as a normal finding.

During ocular examinations, the nurse assesses the movement of the extraocular muscles by stimulating:

Cranial nerves III, IV, and VI.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

The outer layer of the eye is very sensitive to touch.

When examining a patient’s eyes, the nurse uses eye drops to stimulate the sympathetic branch of the autonomic nervous system to

Elevate the eyelid and dilate the pupil

The nurse reviews causes of increased intraocular pressure (IOP) with the patient using the following explanation:

“The pressure results from the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber.”

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

When testing a patient’s visual accommodation the nurse notes a normal finding when the patient demonstrates:

Pupillary constriction when looking at a near object.

The nurse recognizes that a patient has a normal pupillary light reflex when:

Constriction of both pupils occurs in response to bright light.

A mother asks when her newborn infant’s eyesight will be fully developed. The nurse should reply:

"By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object.”

The nurse is reviewing age-related changes of the eye for a class. Which of these physiological changes is responsible for presbyopia?

Loss of lens elasticity

During the health history interview with a 65-year-old male patient of African descent with hypertension, the nurse encourages the patient to have regular eye examinations because of his risk for:

Glaucoma.

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:

Document the findings as common with patient age.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

Use the Snellen chart positioned 20 feet away from the patient.

A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

The patient can read at 20 feet what a person with normal vision can read at 30 feet

A patient is unable to read even the largest letters on the Snellen chart. What should the nurse do next?

Shorten the distance between the patient and the chart until the letters are seen and record that distance

A patient’s vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient has:

Impaired vision.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at the 2 o’clock position in each eye. The nurse should:

Consider this a normal finding.

The nurse is performing the diagnostic positions test and notes normal findings with:

Parallel movement of both eyes.

During eye assessment of a dark-skinned patient, what normal finding does the nurse observe?

Presence of small brown macules on the sclera

A 60-year-old man with suspected ptosis of one eye is at the clinic for an eye examination. The nurse confirms ptosis by:

Observing the distance between the palpebral fissures.

During assessment of the lacrimal apparatus, the nurse would document the following as a normal finding:

Absence of drainage from the puncta when pressing against the inner orbital rim

When assessing the pupillary light reflex, the nurse will

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

During examination of the patient’s eyes, the nurse notes that the pupils become smaller when the patient looks at an object moved closer to the eyes. The nurse will document this finding as:

Accommodation.

When using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in the patient’s pupils. The nurse will:

Continue with the examination knowing that the red glow is a normal finding.

The nurse is examining a patient’s retina with an ophthalmoscope and notes the normal finding of:

An optic disc that is a yellow-orange colour.

When examining a 2-week-old infant the nurse notices that he watches an object but does not follow it with his eyes when moved to different positions. The nurse will:

Document this as a normal finding.

When assessing a male child for colour deficiency the nurse will:

Test for colour vision once between ages 4 and 8 years.

The nurse is conducting an eye-screening clinic at a daycare centre. When examining a 2-year-old child, the nurse suspects that the child has a “lazy eye” and will:

Test for strabismus by performing the corneal light reflex test.

The nurse is performing an eye assessment on an 80-year-old patient and is concerned about finding that the patient has:

Unequal pupillary constriction in response to light.

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

Ask the patient if he or she has a history of heart failure.

When a light is directed across the iris of a patient’s eye from the temporal side, the nurse is assessing for:

Presence of shadows, which may indicate glaucoma.

In a patient who has anisocoria, the nurse would expect to observe:

Pupils of unequal size.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he “can’t see well” from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

Shadow or diminished vision in one quadrant or one-half of the visual field.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

Hordeolum (stye).

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have:

Macular degeneration.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. The nurse recognizes that the patient may have a corneal abrasion when:

There is a shattered look to the light rays reflecting off the cornea.

Papilledema is revealed during an ophthalmic examination which the nurse recognizes as indicating:

Increased intracranial pressure.

During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that appear similar to cotton wool or fluffy clouds. The nurse recognizes that the patient may have:

Diabetes.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye indicating the presence of:

Hyphema.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination reveals that the lower lid is loose and rolling outward. The patient complains of his eye feeling “dry and itchy.” Which action by the nurse is correct?

Assessing for other signs of ectropion

The nurse is administering ear drops to a 68-year-old patient. The nurse will pull the area of the ear consisting of movable cartilage and skin, known as the , upward and backward to open the ear canal.

Auricle

The nurse is examining a patient’s ears and notices a yellow waxy substance in the external canal. The nurse recognizes this:

As protection and lubrication of the ear.

When examining the ear with an otoscope, the nurse notes that the tympanic membrane is translucent and pearly. The nurse will:

Document the finding as normal.

When reviewing the structures of the ear with a class of nursing students, the nurse discusses the importance of the function of the eustachian tube in:

Helping equalize air pressure on both sides of the tympanic membrane.

A patient with a middle ear infection asks the nurse, “What does the middle ear do?” The nurse responds by telling the patient that the middle ear functions to:

Conduct vibrations of sounds to the inner ear.

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?

VIII

The nurse is assessing a patient who may have hearing loss. Which of these statements concerning air conduction is true?

Air conduction is the normal pathway for hearing.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

Ask the patient about current medications.

During an interview, the patient states he has the sensation that “everything around him is spinning.” The nurse recognizes that the portion of the ear responsible for this sensation is the:

Labyrinth

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant’s hearing?

Rubella can damage the infant’s organ of Corti, which will impair hearing.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

“Your son’s eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.”

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of the television or radio. The most likely cause of his hearing loss is:

Otosclerosis.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he “can’t always tell where the sound is coming from” and the words often sound “mixed up.” What might the nurse suspect as the cause for this change?

Nerve degeneration in the inner ear

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. The nurse recognizes this as

A normal finding and that no further follow-up is necessary.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

"Do you have any ear pain or discharge, and if so, when did they occur?”

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

Is a characteristic of recruitment.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include during history taking?

“Does your baby seem to startle with loud noises?”

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Pulling the pinna up and back before inserting the speculum

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

Bloody or clear watery drainage can indicate a basal skull fracture.

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Whisper a set of random numbers and letters and then ask the patient to repeat them.

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:

Perform the otoscopic examination at the end of the assessment.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement regarding this examination is true?

The normal membrane may appear thick and opaque.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:

Turns his or her head to localize the sound.

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?

High-tone frequency loss

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in colour with small vesicles. The nurse would need to know additional information that includes which of these?

Any prolonged exposure to extreme cold

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate:

Acute otitis media.

The mother of a 2-year-old toddler is questioning the need for tympanostomy tubes in her son’s ears. The nurse will provide the following information in the teaching plan:

The tubes will decrease the pressure and allow for drainage.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

Enlarged superficial cervical nodes

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in colour and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:

Most likely has serous otitis media.

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

Could be a potential carcinoma, and the patient should be referred for a biopsy.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Lack of mobility

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at the o'clock position and visible landmarks. The nurse should:

Know that these are scars caused from frequent ear infections.

The nurse is preparing to perform an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure?

Pulling the pinna down

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

Passive cigarette smoke

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest?

Yeast or fungal infection

A 17-year-old student is a swimmer on her high school’s swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:

Use rubbing alcohol or 2% acetic acid eardrops after every swim.

During an examination, the patient states he is hearing a buzzing sound and says, “It is driving me crazy!” The nurse recognizes that this symptom indicates:

Tinnitus.

During an examination, the nurse notices that the patient stumbles a little while walking and that when she sits down, she holds on to the sides of the chair. The patient states, “It feels like the room is spinning!” The nurse documents that the patient is experiencing:

Objective vertigo.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, “I don’t know what the matter is. All of a sudden, I can’t hear you out of my left ear!” What should the nurse do next?

Notify the patient’s health care provider

Which drug is used to reduce intraocular pressure?

osmotic diuretics

Which condition is an indication for the use of direct- and indirect-acting miotics?

Open-angle glaucoma

A patient is being treated for uveitis. Which drug does the nurse expect that the patient is using?

atropine sulphate

Although dipivefrin has localized effects in the eye, it mimics the effects of the sympathetic nervous system neurotransmitters and can cause systemic effects. Which systemic effects can occur?

Increased heart rate or blood pressure

A patient has been taking the corticosteroid dexamethasone (AK Dex®) but has developed bacterial conjunctivitis. The patient is given a prescription for gentamicin (Diogent®) ointment. What interaction is possible if the two drugs are used concurrently?

Immunosuppression may make elimination of the eye infection more difficult.

A patient has been prescribed timolol maleate (Timoptic®) eye drops. What should the nurse tell the patient to do to apply these eye drops properly?

Apply the drops into the conjunctival sac instead of directly onto the eye.

Which medication is used for local anaesthesia in preparation for ocular surgery?

tetracaine (Minims®)

A patient with an eye injury requires an ocular examination to detect the presence of a foreign body. Which drug is used for this examination?

fluorescein sodium (AK-Fluor®)