Exam 3 Medsurg - exam 3 practice PDF

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Chapter 42 The nurse is teaching a group of older adults about basic eye examinations. What would the nurse recommend about the frequency for eye examinations for most people over 65 years of age? a) Every 1 to 2 years b) Every 2 to 4 years c) Every 3 to 5 years d) When the primary health care provider recommends ANS: A

The nurse enters an examination room to help with an eye assessment. The client is directed toward the chart shown below:

What is the primary health care provider assessing? a) Color vision b) Depth perception c) Spatial perception d) Visual acuity

ANS: A

The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse emphasize as possibly indicating beginning cataract formation? a) Diplopia b) Cloudy pupil c) Loss of peripheral vision d) Blurred vision ANS: D

A client had a retinal detachment and has undergone surgical correction. What discharge health teaching is most important for the nurse to include? a). “Avoid reading, writing, or close work such as sewing.” b. “Report immediate loss of vision of pain in the affected eye.” c. “Keep the follow-up appointment with the ophthalmologist.” d. “Remove your eye patch every hour for eyedrops.” ANS: B

A client has been prescribed brinzolamide for glaucoma. What assessment by the nurse requires communication with the primary health care provider? a. Allergy to eggs b. Allergy to sulfonamides c. Use of contact lenses d. Use of beta blockers

ANS: B

The nurse is teaching a client about preventing intraocular pressure increase after cataract surgery. Which health teaching would the nurse include? (Select all that apply.) 1. “Don’t lift objects weighing more than 20 lb (9.1 kg).” 2. “Avoid blowing your nose or sneezing.” 3. c. “Don’t bend down from the waist.” 4. “Don’t strain to have a bowel movement.” 5. “Avoid having sexual intercourse.” 6. “Don’t wear tight shirt or blouse collars.” ANS: B,C,D,E,F

The nurse is assessing a client admitted to the emergency department with possible retinal detachment. What assessment findings would the nurse expect? (Select all that apply.) 1. Presence of bright light flashes 2. Decreased visual field in affected eye 3. Feeling like a curtain is over one eye 4. Gradual changes in visual acuity 5. Painful throbbing in the affected eye ANS: A,B,C

Chapter 43 A nurse is teaching a client about ear hygiene and health. Which statement by the client indicates a need for further teaching? 1. “A soft cotton swab is alright to clean my ears with.” 2. “I make sure my ears are dry after I go swimming.” 3. “I use good earplugs when I practice with the band.” 4. “Keeping my diabetes under control helps my hearing.” ANS: A

The client’s electronic health record indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? 1. “Do you feel like something is in your ear?” 2. “Do you have frequent ear infections?” 3. “Have you been exposed to loud noises?” 4. “Have you been told your ear bones don’t move?” ANS: C

An older adult in the family practice clinic reports a decrease in hearing in one ear for over a week. What action by the nurse is most appropriate? 1. Assess for cerumen buildup. 2. Facilitate audiological testing. 3. Perform tuning fork tests. 4. Review the medication list. ANS: A

A client who has had cold symptoms for a week visits the local urgent care center with report of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings would the nurse expect? 1. High fever 2. Nausea and vomiting 3. Elevated blood pressure 4. Purulent ear drainage ANS: D

The nurse is teaching a client about factors that can cause external otitis. Which of these factors would the nurse emphasize as the highest risk? 1. Excess cerumen 2. Swimming 3. Sinus congestion 4. Meniere disease ANS: B

A client with MEniFre disease is in the hospital when the client has an episode of this disorder. What action by the nurse is appropriate? 1. 2. 3. 4.

Assess vital signs every 15 minutes. Dim or turn off lights in the client’s room. Place the client in bed with the upper side rails up. Provide a cool, wet cloth for the client’s face.

ANS: C

The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by the nurse is most appropriate?

r Bea.chCmOMonth for wax 1. “Visit your primary health care provideA removal.” 2. “Drink plenty of water and other liquids to prevent hardening of the ear

wax.” 3. “Irrigate each ear once a month to remove wax and prevent was

buildup.” 4. “Put one drop of mineral oil in each ear once a week at bedtime.” ANS: D

The nurse is assessing a client’s medication profile to determine risk for tinnitus. Which drug classification is most likely to cause this health problem? 1. Cephalosporins 2. NSAIDs 3. Beta-adrenergic blockers 4. Osmotic diuretics ANS: B

A client has a hearing aid. What care instructions does the nurse provide the assistive personnel (AP) in the care of this client? (Select all that apply.)

GRADESLAB.COM 1. “Be careful not to drop the hearing aid when handling.” 2. “Soak the hearing aid in hot water for 20 minutes.” 3. “Turn the hearing aid off when the client goes to bed.” 4. “Use a toothpick to clean debris from the device.” 5. “Wash the device with soap and a small amount of warm water.”

6. “Avoid using hair or cosmetic products near the hearing aid.” ANS: A,C,D,F

Chapter 41

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client’s neurologic examination is normal. About what drug would the nurse plan to teach the patient? 1. Alteplase 2. Clopidogrel 3. Heparin sodium 4. Mannitol ANS: B

The nurse is taking a history from a daughter about her father’s onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? 1. Client’s symptoms occurred slowly over several hours. 2. Client because increasingly lethargic and drowsy.

3. Client reported severe headache before other symptoms. 4. Client has a long history of atrial fibrillation. ANS: D

The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse’s teaching? 1. “I will use “yes” and “no” questions when communicating with the

client.” 2. “I will remind the client frequently to not get out of bed without help.” 3. “I will offer a urinal every hour to the client due to incontinence.” 4. “I will feed the client slowly using soft or pureed foods.” ANS: B

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? 1. Loss of bladder control 2. Other medical conditions 3. Progression of symptoms 4. Time of symptom onset ANS: D

A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client’s plan of care?

1. Ambulate only with a gait belt. 2. Encourage double swallowing. 3. Monitor lung sounds after eating. 4. Perform postvoid residuals. ANS: A

A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? 1. A 27-year-old heavy-cocaine user. 2. A 30-year-old who drinks a beer a day. 3. A 40-year-old who uses seasonal antihistamines. 4. A 65-year-old who is active and on no medications. ANS: A

The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? 1. Projectile vomiting 2. Dilated and nonreactive pupils 3. Severe hypertension 4. Decreased level of consciousness ANS: D

A client is admitted with a traumatic brain injury. What is the nurse’s priority assessment? a. Complete neurologic assessment 2. Comprehensive pain assessment 3. Airway and breathing assessment 4. Functional assessment ANS: C

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine ANS: C

Chapter 40

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? 1. Peripheral edema 2. Facial flushing

3. Tachycardia 4. Fever ANS: B

The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client’s care? a. Fracture b. Malabsorption c. Delirium d. Anemia ANS: A

A nurse assesses clients at a community center. Which client is at greatest risk for low back pain? 1. A 24-year-old female who is 25 weeks pregnant. 2. A 36-year-old male who uses ergonomic techniques. 3. A 53-year-old female who uses a walker. 4. A 65-year-old female with osteoarthritis. ANS: D

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client’s coping strategies? (Select all that apply.) 1. Spiritual beliefs 2. Level of pain

3. Family support 4. Level of independence 5. Annual income 6. Previous coping strategies ANS: A,C,D,F

A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client’s plan of care? (Select all that apply.) 1. Remove the vest for client bathing. 2. Assess the pin sites for signs of infection. 3. Loosen the pins when sleeping. 4. Decrease the patient’s oral fluid intake. 5. Assess the chest and back for skin breakdown. ANS: B,E

A nurse assesses a client who is recovering from an open traditional anterior cervical fusion. Which assessment findings would alert the nursing to a complication from this procedure? (Select all that apply.) 1. Difficulty swallowing 2. Hoarse voice 3. Constipation 4. Bradycardia 5. Hypertension ANS: A,B

The nurse is taking a history on an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.) 1. Scoliosis 2. Spinal stenosis 3. Hypocalcemia 4. Osteoporosis 5. Osteoarthritis ANS: A,B,C,D,E

Chapter 39

A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which

nursing action is most appropriate to manage this client’s dementia?

GRADESLAB.COM 1. 2. 3. 4.

Provide animal-assisted therapy as needed. Ensure a structured and consistent environment. Assist the client with activities of daily living (ADLs). Use validation therapy when communicating with the client.

ANS: B

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? 1. “Provide periods of exercise and rest for the client.” 2. “Place a padded throw rug at the bedside.” 3. “Provide a highly stimulating environment.” 4. “Install safety locks on all outside doors.” ANS: D

The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? 1. Bronchial asthma 2. Heart disease 3. Diabetes mellitus 4. Rheumatoid arthritis ANS: B

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? 1. “Do you live in a crowded residence?” 2. “When was your last tetanus vaccination?” 3. “Have you had any viral infections recently?” 4. “Have you traveled out of the country in the last month?” ANS: A

A nurse assesses a client who is recovering from the implantation of a vagal nerve-stimulation device. For which signs and symptoms would the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures ANS: C,D

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) 1. Flexed trunk 2. Long, extended steps 3. Slow movements 4. Uncontrolled drooling 5. Tachycardia ANS: A,C,D

The nurse is caring for a client who has Alzheimer disease. The client’s wife states, “I am having trouble managing his behaviors at home.” Which questions would the nurse ask to assess potential causes of the client’s behavior problems? (Select all that apply.) 1. “Does your husband bathe and dress himself independently?” 2. “Do you weigh your husband each morning around the same time?” 3. “Does his behavior become worse around large crowds?” 4. “Does your husband eat healthy foods including fruits and

vegetables?”

5. “Do you have a clock and calendar in the bedroom and kitchen?” ANS: A,C,E

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) 1. Immobile 2. Has difficulty driving c. Wandering 4. ADL dependent 5. Incontinent 6. Possible seizures

GRADESLAB.COM ANS: A,D,E,F

Chapter 38

A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider? 1. 2. 3. 4.

Mild temporal headache Pupils equal and react to light d. “I ate oatmeal with wheat toast and orange juice for breakfast.” Alert and oriented  3

ANS: D

A nurse plans care for a 77-year-old client who is experiencing age-related peripheral sensory perception changes. Which intervention would the nurse include in this client’s plan of care? a. Provide a call button that requires onl

A nurse assesses a client and notes the client’s position as indicated in the illustration below:

How would the nurse document this finding? 1. 2. 3. 4.

Decorticate posturing Decerebrate posturing Atypical hyperreflexia Spinal cord degeneration

ANS: A

A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How would the nurse document this client’s assessment using the Glasgow Coma Scale shown below?

GARDESLAB.COM Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

a. 8 b. 10 c. 12 d. 14

ANS: C

An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline. Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.) 1. Chronic hearing loss 2. Infection

3. Drug toxicity 4. Dementia 5. Hypoxia 6. Aging ANS: B,C,E

A nurse assesses an older client. Which assessment findings would the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)

GRADESLAB.COM DIF: Applying TOP: Integrated Process: Culture and Spirituality KEY: Neurologic assessment, Changes associated with aging MSC: Client Needs Category: Health Promotion and Maintenance

GARDESLAB.COM Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) 1. Long-term memory loss 2. Slower processing time 3. Increased sensory perception 4. Decreased risk for infection 5. Change in sleep patterns ANS: B,E...