Visual System
The nurse is evaluating the effectiveness of treatment for the patient who has myopia and presbyopia by assessing the patient's ____________ and ___________ visions.
What is near vision and distant vision? - The treatment for myopia and presbyopia includes lenses. To evaluate the effectiveness of the lenses for the patient, the nurse would assess the patient's ability to see near and distant objects.
When performing an ear exam, the nurse should choose a speculum that is larger than the canal. True or False
What is FALSE? - Speculum should be smaller than the ear canal to prevent damage.
Chronic scratching or rubbing of the skin can lead to thickening of the epidermis, also known as _______.
What is lichenification?
The patient who suffered from an extensive and severe burn injury will need nutrition therapy delivered by which route?
What is enteral nutrition? - Can be started during the emergent phase and increased as needed to meet metabolic needs.
The type of IV solution typically used for IV fluid replacement of burn injuries.
What is Lactated Ringer's?
Which of these are NOT normally occurring changes with aging?
a. Light yellowish color of sclera
b. Slower recovery time of pupil
c. Persistent photophobia
What is persistent photophobia? - This assessment finding would require further assessment.
When performing an ear irrigation for cerumen impaction, the nurse should choose the temperature solution.
What is body-temperature solution?
This type of diagnostic study is performed for superficial lesions, by scraping the skin using a razor blade to obtain a specimen.
What is a shave biopsy?
What is circumferential burn? - Monitoring pulses and circulation is priority with circumferential burns and the HCP must be notified of any abnormal findings immediately.
Based on the Rule of Nines, a patient who has suffered a burn to their back has a TBSA burned of ________.
What is 18%?
What is cataract development? - Clouding of the lens causes light to scatter and can cause sensitivity to light as well as blurred vision.
Stress reduction such as quiet environment with no television should be implemented for the patient who is experiencing an acute attack of this.
What is Meniere's disease? - The patient with Meniere's disease often experiences vertigo, nausea, and is at risk for falls. It can help the patient to provide a calm environment with decreased stressors that may exacerbate symptoms.
Cyanosis in dark-skinned persons is easier assessed this way.
What is oral mucous membranes and nail beds?
The patient who was in a house fire suddenly becomes agitated and restless in the hospital. The nurse suspects the patient has suffered from __________________.
What is smoke inhalation injury? - Altered mental status may indicate hypoxia so the nurse must assess oxygen saturation with any changes.
Laboratory results during the emergent phase would reflect a(n) _______________ in hematocrit.
What is an increase? - During the emergent phase, capillary permeability is increased leading to leakage of water, sodium and proteins from the intravascular spacing, resulting in hemoconcentration.
Describe the instructions for completing a visual acuity exam.
What is Stand 20 feet from chart, cover one eye and read the lines, cover the other eye and read the lines? - The Snellen chart is used to test visual acuity, having the patient stand 20 feet from the chart.
The patient with hearing aids should first try them in a loud, crowded environment. True or False
What is FALSE?
For the patient with this type of burn injury, it is important for the nurse to assess for spinal injury.
What is an electrical burn injury?
During the emergent phase of a burn injury, the patient with an increased hematocrit suggestive of hemoconcentration will need which nursing intervention?
What is an increase in IV fluid replacement? -
The ability of the lens to adjust to various distances is known as __________________.
What is accommodation? - The patient who has normal accommodation pupils will constrict as an object is being moved toward the patients eye.
How can the nurse accommodate the environment of an elderly patient who has diminished sensitivity to high-pitched sounds and is unable to filter out unwanted noises?
What is ask to turn off the television during conversations? - Elderly patients have more difficulty filtering out unnecessary sounds and may not be able to be present for conversations or patient teaching.
The most effective method for infection prevention and control of spread to others during wound dressing changes is by _____________________.
What is strict handwashing and proper disposal of soiled dressings?
When replacing fluids during the emergent phase of a burn injury, the nurse should plan to administer how much of the total volume in the first 8 hours?
What is half of the total volume?
What is urine output? - Should be monitored hourly.