Sensory
Which symptom indicates diplopia?
1. Discomfort in the eye
2. Inability to perceive light from dark
3. Seeing two overlapping images
4. Discharge of clear, watery fluid
3. Seeing two overlapping images
Diplopia is a condition in which the client sees two overlapping images because the eyes are unable to focus on an object and move in unison.
Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? (SATA)
a) Anemia
b) Diabetes mellitus
c) Hepatitis
d) Hypertension
e) Multiple sclerosis (MS)
b,d,e
clients with DM are at an increased risk for diabetic retinopathy
clients with HTN are at an increased risk for retinal damage
the client with MS can have neurological effects that impact visual acuity
A client's altered body image is evidenced by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem?
A. The client will consume adequate calories to sustain normal weight.
B. The client will cease strenuous exercise programs.
C. The client will perceive an ideal body weight and shape as normal.
D. The client will not express a preoccupation with food.
ANS: C
The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.
A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data?
A. Compulsive personality disorder
B. Schizotypal personality disorder
C. Histrionic personality disorder
D. Manic personality disorder
C
The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.
A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention, and the rationale for this action?
A. Administering lorazepam (Ativan) prn because the client is angry about the discovery of the note
B. Establishing room restrictions because the client's threat is an attempt to manipulate the staff
C. Placing this client on one-to-one suicide precautions because the more specific the plan, the more likely the client will attempt suicide
D. Calling an emergency treatment team meeting because the client's threat must be addressed
C
The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.
Which eye disorder is diagnosed in a child who complains of clouding or haziness of the corneal lens?
1. Color blindness
2. Glaucoma
3. Cataract
4. Hyphema
3. Cataract
Clouding or haziness of the corneal lens is known as cataract. Cataracts can be present in one or both eyes.
Which client is most in need of immediate examination by an ophthalmologist?
a) A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged
b) A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights
c) A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes
d) A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes
b
the client is exhibiting signs of increased IOP- this client needs to be assessed first due to the possibility of blindness
A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding?
A. The emesis produced during purging is acidic and corrodes the tooth enamel.
B. Purging causes the depletion of dietary calcium.
C. Food is rapidly ingested without proper mastication.
D. Poor dental and oral hygiene leads to dental caries.
ANS: A
The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.
Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?
A. Being firm, consistent, and empathic, while addressing specific client behaviors
B. Promoting client self-expression by implementing laissez-faire leadership
C. Using authoritative leadership to help clients learn to conform to society norms
D. Overlooking inappropriate behaviors to avoid promoting secondary gains
A
The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction such as manipulation and splitting.
Which nursing intervention strategy is most appropriate to implement initially with a suicidal client?
A. Ask a direct question such as, "Do you ever think about killing yourself?"
B. Ask client, "Please rate your mood on a scale from 1 to 10."
C. Establish a trusting nurse-client relationship.
D. Apply the nursing process to the planning of client care.
A
The risk of suicide is greatly increased if the client has suicidal ideations, has developed a plan, and particularly if means exist for the client to execute the plan.
a 60 year notice decline in visual acuity and ask if it could be from a cataract. Which question will help determine if a cataract is developing?
1. has your ability to perceive colors changed
2. does your vision appear distorted or wavy
3. does the center of your visual field appear dark
4. do you see random flashes of bright light
1
cataract formation involves the lens of the eye becoming more opaque, thus decreasing the vibrancy of colors.
A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure?
a) Burning in the eye
b) Inability to differentiate colors
c) Increased sensitivity to light
d) Gradual vision changes
d
indicates an increase in IOP
A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred?
A. "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not."
B. "Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not."
C. "Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not."
D. "Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not."
ANS: A
The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food followed by purging.
Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply?
A. "Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone."
B. "Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, while clients diagnosed with avoidant personality disorder do not."
C. "Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant."
D. "Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, while clients diagnosed with avoidant personality disorder remain based in reality."
A
The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.
How would a nurse differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder?
A. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not.
B. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not.
C. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions.
D. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.
A
A client diagnosed with OCD experiences both obsessions and compulsions. Clients diagnosed with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control.
A patient reports eye pain and states "I suddenly just felt something hit my eye." Which order by the ER physician might the nurse question?
a) order for an x-ray
b) order for a CT scan
c) order for an MRI
c
MRI contraindicated b/c it may move any metal-containing projectile from the eye & cause more injury
A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider?
a) Increased tearing
b) Itching of the eye
c) Reduction in vision
d) Swollen eyelid
c
the client should notify the HCP immediately
A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100 mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense?
A. 25 mL
B. 20 mL
C. 15 mL
D. 10 mL
ANS: C
Twenty mg of Prozac multiplied by three results in the calculated 60 mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.
Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder?
A. The client experiences unwanted, intrusive, and persistent thoughts.
B. The client experiences unwanted, repetitive behavior patterns.
C. The client experiences inflexibility and lack of spontaneity when dealing with others.
D. The client experiences obsessive thoughts that are externally imposed.
C
The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.
A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation?
A. Assessing the client's pulse oximetry and vital signs
B. Developing a plan for safety for the client
C. Assessing the client for suicidal ideations
D. Establishing a trusting nurse-client relationship
A
It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow's hierarchy of needs. This client's problems with oxygenation will take priority over assessing for current suicidal ideations.
Which eye procedure requires informed consent from the client?
a) Eyedrop instillation
b) Fluorescein angiography
c) Ophthalmoscopy
d) Snellen test
b
An invasive test and requires informed consent
The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (SATA)
a) Bending over to tie shoes
b) Sitting with legs elevated
c) Sleeping on more than two pillows
d) Blowing the nose frequently
e) Lifting objects weighing more than 10 pounds
a,d,e
anything that increases IOP is contraindicated for the client with glaucoma
A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4" (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can't remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has:
A. bulimia nervosa.
B. anorexia nervosa.
C. depression.
D. schizophrenia.
B. anorexia nervosa
Rationale: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. Typically, the client is hypotensive and dehydrated. Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting. Although depression may be accompanied by weight loss, it isn't characterized by a body image disturbance or the intense fear of obesity seen in anorexia nervosa. Schizophrenia may cause bizarre eating patterns, but it rarely causes the full syndrome of anorexia nervosa.
When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome?
A. To stabilize pathology with the correct combination of medications
B. To change the characteristics of the dysfunctional personality
C. To reduce inflexibility of personality traits that interfere with functioning and relationships
D. To decrease the prevalence of neurotransmitters at receptor sites
C
The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.
Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? Select all that apply.
a."Are there certain social situations that cause you to feel especially uncomfortable?"
b."Are there others in your family who must do things in a certain way to feel comfortable?"
c."Have you been a victim of a crime or seen someone badly injured or killed?"
d."Is it difficult to keep certain thoughts out of your awareness?"
e."Do you do certain things over and over again?"
B, D, E
The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia. See relationship to audience response question.