Unbreakable
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?
1.
Diplopia
2.
Eye pain
3.
Floating spots
4.
Blurred vision
Answer: 4
Rationale:
A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.
Client Needs: Physiological Integrity
Cognitive Ability: Analyzing
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Cataracts
Integrated Process: Nursing Process/Assessment
Priority Concepts: Clinical Judgment, Sensory Perception
Strategy(ies): Strategic Words
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?
1.
Clear mentation
2.
Minimal dyspnea
3.
Oxygen saturation of 85%
4.
Arterial oxygen level of 78 mm Hg
Answer: 1
Rationale:
An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%.
The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client?
1.
Maintain a supine position.
2.
Change the ear dressing daily.
3.
Monitor for signs of facial nerve injury.
4.
Position the client on the affected side to promote drainage.
Answer: 3
Rationale:
After mastoidectomy, the nurse should assess for signs of facial nerve injury (cranial nerve VII), such as facial drooping. The nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also should monitor for signs of pain, dizziness, or nausea. The client should be instructed to lie on the unaffected side to prevent disruption of the surgical site. The head of the bed should be elevated at least 30 degrees. The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively.
The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?
1.
"I will wash my face with cotton pads."
2.
"I'll have to start chewing on my unaffected side."
3.
"I should rinse my mouth if toothbrushing is painful."
4.
"I'll try to eat my food either very warm or very cold."
Answer: 4
Rationale:
Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.
The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem?
1.
A 25-year-old woman who runs
2.
A 36-year-old man who has asthma
3.
A 70-year-old man who consumes excess alcohol
4.
A sedentary 65-year-old woman who smokes cigarettes
Answer: 4
Rationale:
Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.
The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?
1.
Calcium level of 9.0 mg/dL (2.25 mmol/L)
2.
Uric acid level of 9.0 mg/dL (540 mcmol/L)
3.
Potassium level of 4.1 mEq/L (4.1 mmol/L)
4.
Phosphorus level of 3.1 mg/dL (1.0 mmol/L)
Answer: 2
Rationale:
In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL (480 mcmol/L); a normal value for a male ranges from 4.0 to 8.5 mg/dL (240–501 mcmol/L) and for a female, from 2.7 to 7.3 mg/dL (160–430 mcmol/L). Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.
The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma?
1.
Client report of blurred vision
2.
Client report of "tunnel vision"
3.
Client report of ocular erythema
4.
Client report of halos around lights
Answer: 2
Rationale:
POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.
Client Needs: Physiological Integrity
Cognitive Ability: Analyzing
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Glaucoma
Integrated Process: Nursing Process/Assessment
Priority Concepts: Clinical Judgment, Sensory Perception
Strategy(ies): Subject
A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?
1. Increase sodium in the diet.
2. Avoid sudden head movements.
3. Lie still and watch the television.
4. Increase fluid intake to 3000 mL a day.
Answer: 2
Rationale:
The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.
Client Needs: Safe and Effective Care Environment
Cognitive Ability: Applying
Content Area: Adult Health: Ear
Health Problem: Adult Health: Ear: Vertigo/Tinnitus
Integrated Process: Teaching and Learning
Priority Concepts: Client Education, Safety
Strategy(ies): Subject
The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk?
1.
Yogurt
2.
Turkey
3.
Shellfish
4.
Spaghetti
Answer: 1
Rationale:
The major dietary source of calcium is from dairy products including milk, yogurt, and a variety of cheeses. Calcium also can be added to certain products such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements also are available and recommended for persons with typically low calcium intake. Turkey, shellfish, and spaghetti are not high-calcium products.
A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?
1.
Allowing bathroom privileges only
2.
Elevating the head of the bed to 45 degrees
3.
Wearing dark glasses to read or watch television
4.
Placing an eye patch over the client's affected eye
Answer: 4
A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?
Rationale:
The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client's position is prescribed by the primary health care provider; normally, the prescription is to lie flat.
Client Needs: Physiological Integrity
Cognitive Ability: Analyzing
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Retinal Detachment
Integrated Process: Nursing Process/Planning
Priority Concepts: Sensory Perception, Safety
Strategy(ies): Subject
The nurse is reviewing the primary health care provider's prescriptions for a client with Ménière's disease. Which diet would most likely be prescribed for the client?
1.
Low-fat diet
2.
Low-sodium diet
3.
Low-cholesterol diet
4.
Low-carbohydrate diet
Answer: 2
Rationale:
Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for a client with Ménière's disease. The diets in the remaining options are not specific to the client with Ménière's disease.
A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury?
1.
Strain
2.
Sprain
3.
Fracture
4.
Contusion
Answer: 3
Rationale:
Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign or symptom. A strain results from a pulling force on the muscle, resulting in soreness and pain with muscle use. A sprain is an injury to a ligament caused by a wrenching or twisting motion and is manifested by pain, swelling, and inability to use the joint or bear weight normally. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.
A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the primary health care provider will include a new prescription for which vitamin supplement?
1.
A
2.
D
3.
E
4.
K
Answer: 2
Rationale:
Osteomalacia technically refers to bone softening that results from demineralization of bone matrix and failure to calcify. A common cause is vitamin D deficiency in the diet. Other causes are inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with absorption and metabolism of vitamin D. Deficiencies of the vitamins noted in the remaining options are not associated with osteomalacia.
The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome?
1.
Cold, bluish-colored fingers
2.
Numbness and tingling in the fingers
3.
Pain that increases when the arm is dependent
4.
Pain that is out of proportion to the severity of the fracture
Answer:2
Rationale:
The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.
The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)?
1.
The client's mobility status
2.
The renal and endocrine systems
3.
The cardiovascular and renal systems
4.
The neurological and respiratory systems
Answer: 4
Rationale:
The early signs of the complication of fat embolism include changes in the client's mental status and signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairments are likely to be secondary to impaired respiratory function. Effects on the endocrine system usually are not seen. The client's mobility status is unrelated to the signs of fat embolism.
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?
1.
"I can sit down to put on my pants and shoes."
2.
"My son removed all loose rugs from my bedroom."
3.
"I try to exercise every day and rest when I'm tired."
4.
"I don't need to use my walker to get to the bathroom."
Answer: 4
Rationale:
The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.
A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the primary health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours?
1.
"I should place hot packs on my ankle."
2.
"I should wrap my ankle with blankets."
3.
"I should elevate my foot above the level of the heart."
4.
"I should try to ambulate at least 10 minutes out of every hour."
Answer: 3
Rationale:
Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on health care provider prescription. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position.
A client being prepared for a myringotomy asks the nurse about the procedure. The nurse should respond by making which statement?
1.
"This procedure involves removing a bone from the ear."
2.
"This procedure will reduce the pressure you feel in your ear and allow fluid to drain."
3.
"This procedure involves removing the eardrum and inserting a mechanical bone in the ear."
4.
"This procedure involves removal of middle ear and inserting a ring around the ear bones that will vibrate on sound to promote better hearing."
Answer: 2
Rationale:
A myringotomy is a surgical procedure that allows fluid to drain from the middle ear. A small incision is created in the eardrum (tympanic membrane) to relieve pressure that may be caused by excessive buildup of fluid. A tympanostomy tube is inserted into the eardrum to keep the middle ear aerated and to prevent reaccumulation of fluid. A mastoidectomy, in which the mastoid bone is removed or partially removed, may be recommended to treat chronic otitis media that is resistant to other therapies. The tympanic membrane is a structure needed to transmit sound from the air to the ossicles inside the middle ear and then to the oval window in the fluid-filled cochlea. Thus, it ultimately converts and amplifies vibration in air to vibration in fluid. Therefore, options 1, 3, and 4 are incorrect descriptions.
The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities?
1.
Muscle metabolism and growth
2.
Bone resorption and regeneration
3.
Nervous system impulse transmission
4.
Joint integrity and synovial fluid production
Answer: 2
Rationale:
Paget's disease is characterized by skeletal deformities resulting from abnormal bone resorption followed by abnormal regeneration. It is not caused by problems with muscle, nervous system, or joint functioning.
The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease?
1.
Tinnitus
2.
Fatigue
3.
Bone pain
4.
Difficulty with ambulating
Answer: 3
Rationale:
Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Bone pain is the most common symptom of Paget's disease and may manifest in areas close to a joint. The pain is related to progressive enlargement and deformity of the bone. Hearing loss, numbness of the face, or (more rarely) blindness can occur when the thickened bone of Paget's disease compresses vital nerves in the skull. Fatigue or difficulty with ambulation may occur but would not be the most common symptom.
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply.
1.
Padding the side rails of the bed.
2.
Placing an airway at the bedside.
3.
Placing the bed in the high position.
4.
Putting a padded tongue blade at the head of the bed.
5.
Placing oxygen and suction equipment at the bedside.
6.
Flushing the intravenous catheter to ensure that the site is patent.
Answer: 1, 2, 5, 6
Rationale:
Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.
1.
Loosening restrictive clothing.
2.
Restraining the client's limbs.
3.
Removing the pillow and raising padded side rails.
4.
Positioning the client to the side, if possible, with the head flexed forward.
5.
Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.
Answer: 1, 3, 4
Rationale:
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.
Client Needs: Physiological Integrity
Cognitive Ability: Applying
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Seizure Disorder/Epilepsy
Integrated Process: Nursing Process/Implementation
Priority Concepts: Intracranial Regulation, Safety
Strategy(ies): Subject
The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks?
1.
"I need to restrict my carbohydrate intake."
2.
"I need to drink at least 3 L of fluid per day."
3.
"I need to maintain a low-fat and low-cholesterol diet."
4.
"I need to be sure to consume foods that are low in sodium."
Answer: 4
Rationale:
Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease.
The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching?
1.
"A bone fragment has injured the nerve supply in the area."
2.
"An injured artery caused impaired arterial perfusion through the compartment."
3.
"Bleeding and swelling caused increased pressure in an area that couldn't expand."
4.
"The fascia expanded with injury, causing pressure on underlying nerves and muscles."
Answer: 3
Rationale:
Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The remaining options are inaccurate descriptions of compartment syndrome.
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?
1.
"We need to discourage him from wearing eyeglasses."
2.
"We need to place objects in his impaired field of vision."
3.
"We need to approach him from the impaired field of vision."
4.
"We need to remind him to turn his head to scan the lost visual field."
Answer: 4
Rationale:
Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
Client Needs: Safe and Effective Care Environment
Cognitive Ability: Evaluating
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Stroke
Integrated Process: Nursing Process/Evaluation
Priority Concepts: Intracranial Regulation, Safety
Strategy(ies): Comparable or Alike Options, Subject