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Which information will the nurse include when teaching a patient about routine glaucoma testing?

a. The test involves reading a Snellen chart at a distance of 20 feet.
b. Application of a Tono-pen to the surface of the eye will be needed.
c. The examination includes checking the pupil's reaction to a bright light.
d. Medications to dilate the pupil will be used before testing for glaucoma.

b. Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders.

Which assessment information obtained by the nurse when performing an eye examination for a 78-year-old patient indicates that more extensive examination of the eyes is needed?

a. The patient's sclerae are light yellow in color.
b. The patient complains of persistent photophobia.
c. The pupil recovers slowly after being stimulated by a penlight.
d. There is a whitish gray ring encircling the periphery of the iris.

b. Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 78-year-old patient.

When performing an eye examination, the nurse will assess for accommodation by

a. covering one eye for 1 minute and noting the pupil reaction when the cover is removed.
b. shining a light into the patient's eye and watching the pupil response in the opposite eye.
c. observing the pupils when the patient focuses on a close object and then on a distant object.
d. touching the patient's pupil with a small piece of sterile cotton and watching for a blink reaction.

C
Accommodation is defined as the ability of the lens to adjust to various distances. The other nursing actions also may be part of the eye examination, but they do not test for accommodation.

The nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from ultraviolet light because ultraviolet sunlight exposure is associated with the development of

a. cataracts.
b. glaucoma.
c. anisocoria.
d. exophthalmos.

A
Ultraviolet light exposure is associated with the accelerated development of cataracts. Glaucoma is caused by increased intraocular pressure, exophthalmos is associated with hyperthyroidism, and anisocoria can occur normally in a small percentage of the population or may be caused by injury or central nervous system disorders.

Assessment of a patient'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. The nurse records which of the following findings as visual acuity?

a. OS 20/40; OD 20/50
b. OU 20/40; OS 50/20
c. OD 20/40; OS 20/50
d. OU 40/20; OD 50/20

A
When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.

Which nursing action is included when assessing a patient's visual field?

a. Position the patient 20 feet from the Snellen chart.
b. Have the patient cover one eye while facing the nurse.
c. Instruct the patient to follow a moving object using only the eyes.
d. Shine a light into one pupil and observe the response for both pupils.

B
To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. The other actions are needed to test for visual acuity, extraocular movements, and consensual pupil response

The nurse is observing a student who is preparing to perform an ear examination of a 24-year-old patient. The nurse will need to intervene if the student

a. chooses a speculum smaller than the ear canal.
b. pulls the auricle of the ear down and backward.
c. stabilizes the hand holding the otoscope on the patient's head.
d. stops inserting the otoscope after observing impacted cerumen.

B
The auricle should be pulled up and back when assessing an adult. The other actions are appropriate when performing an ear examination.

When obtaining a health history from a 52-year-old patient, which patient statement is most important to communicate to the health care provider?

a. "My vision seems blurry now when I read."
b. "I have noticed that my eyes are drier now."
c. "It is hard for me to see when I drive at night."
d. "The peripheral part of my vision is decreased."

D
The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.

The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a new patient at the eye clinic. Which information given by the patient will have the most implications for the patient's treatment?

a. "I use aspirin when I have a sinus headache."
b. "I have had frequent episodes of conjunctivitis."
c. "I take metoprolol (Lopressor) daily for angina."
d. "I have not had an eye examination for 10 years."

C
It is important to note whether the patient takes any β-adrenergic blockers because this category of medications also is used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

In order to assess the visual acuity for a patient in the outpatient clinic, the nurse will need to obtain a (an)

a. penlight.
b. Amsler grid.
c. Snellen chart.
d. ophthalmoscope.

C
The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and Amsler grid also may be used during an eye examination, but they are not helpful in assessing visual acuity.

A patient being admitted to the hospital 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 nursing diagnosis will the nurse include in the plan of care?

a. Risk for falls related to current decrease in stereoscopic vision
b. Ineffective health maintenance related to inability to see surroundings
c. Disturbed body image related to eye trauma and need to wear eye patch
d. Ineffective denial related to inability to admit the impact of the eye injury

A
The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective denial, disturbed body image, or ineffective health maintenance.

A patient in the eye clinic is scheduled for refractometry. Which information will the nurse include in patient teaching?

a. "You will need to wear sunglasses for a few hours after the exam."
b. "The surface of your eye will be numb while the doctor does the exam."
c. "You should not take any of your eye medicines before the examination."
d. "The doctor will shine a bright light into your eye during the examination."

A
The pupil is dilated by using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

The nurse is assessing a 48-year-old patient for presbyopia. Which equipment will the nurse need to obtain before the examination?

a. Penlight
b. Tono-pen
c. Jaeger chart
d. Snellen chart

C
Presbyopia is the normal loss of near vision that occurs with age and is assessed using a Jaeger chart. The Snellen chart, penlight, and the Tono-pen are used when assessing for other visual disorders.

A patient arrives in the emergency department complaining of eye itching and pain caused by sleeping with contact lenses in place. To facilitate further examination of the eye, the nurse will anticipate the need for

a. a tonometer.
b. eye patching.
c. a refractometer.
d. fluorescein dye.

D
Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be visualized using fluorescein dye. The other items listed would not be helpful in determining the cause of this patient's symptoms.

During the nursing history, a patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about

a. tympanometry.
b. rotary chair testing.
c. pure-tone audiometry.
d. bone-conduction testing.

B
The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I always sleep with the radio on." Which follow-up question is most appropriate to obtain more information about possible hearing problems?

a. "Do you grind your teeth at night?"
b. "What time do you usually fall asleep?"
c. "Have you noticed any ringing in your ears?"
d. "Are you ever dizzy when you are lying down?"

C
Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Have you noticed any ringing in your ears?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

Which finding by the nurse during the admission assessment for a patient may indicate that the patient is at risk for falls while hospitalized?

a. Lateralization with Weber test
b. Positive result for Rinne testing
c. Inability to hear a low-pitched whisper
d. Nystagmus when head is turned rapidly

D
Nystagmus suggests that the patient may have problems with balance related to disease of the vestibular system. The other tests are used to check hearing; abnormal results for these do not indicate potential problems with balance

When taking a health history from a new patient in the outpatient clinic, which information may indicate the need to perform a focused hearing assessment?

a. The patient uses albuterol (Proventil) for acute asthma.
b. The patient takes atenolol (Tenormin) to prevent angina.
c. The patient uses acetaminophen (Tylenol) frequently for headaches.
d. The patient has taken ibuprofen (Advil) for 20 years to treat arthritis.

D
Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

Which action will the nurse include in the plan of care for a patient who has vestibular disease?

a. Check Rinne and Weber tests.
b. Face the patient when speaking.
c. Enunciate clearly when speaking.
d. Monitor the patient's ability to ambulate safely.

D
Vestibular disease affects balance so the nurse should monitor the patient during activities that require balance. The other action might be used for patients with hearing disorders.

The nurse in the eye clinic is examining a 65-year-old patient who says "I see small spots that move around in front of my eyes." Which action will the nurse take first?

a. Immediately have the ophthalmologist evaluate the patient.
b. Explain that spots and "floaters" are a normal part of aging.
c. Inform the patient that these spots may indicate damage to the retina.
d. Use an ophthalmoscope to examine the posterior chamber of the eyes.

D
Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

Which observation by the nurse when examining a patient's auditory canal and tympanic membrane is a priority to report to the health care provider?

a. There is a cone of light visible.
b. The tympanum is bluish-tinged.
c. Cerumen is present in the auditory canal.
d. The skin in the ear canal is dry and scaly.

B
A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

A patient is seen in the ophthalmology clinic and diagnosed with recurrent staphylococcal and seborrheic blepharitis. The nurse will plan to teach the patient about

a. saline irrigation of the eyes.
b. surgical removal of the lesion.
c. using baby shampoo to clean the lids.
d. the use of cool compresses to the eyes.

C
Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

Which action should the nurse take when assisting a totally blind patient to walk to the bathroom?

a. Take the patient by the arm and lead the patient slowly to the bathroom.
b. Have the patient place a hand on the nurse's shoulder and guide the patient.
c. Stay beside the patient and describe any obstacles on the path to the bathroom.
d. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

D
When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient

Which topic will the nurse include in patient teaching after a patient has had outpatient cataract surgery and lens implantation?

a. Use of oral opioids for pain control
b. Administration of antibiotic eyedrops
c. Importance of coughing and deep breathing exercises
d. Need for bed rest for the first 24 hours after the surgery

B
Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery, and the patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed since a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

In reviewing a 50-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess

a. visual acuity.
b. pupil reaction.
c. color perception.
d. peripheral vision.

D
The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse will evaluate the patient for improvement in

a. eye pain.
b. visual field.
c. blurred vision.
d. depth perception.

B
POAG develops slowly and without symptoms except for a gradual loss of visual field. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is

a. "These are normal side effects of the drug, which should become less noticeable with time."
b. "If you occlude the puncta after you administer the drops, it will help relieve these side effects."
c. "The drops are uncomfortable, but it is very important for you to use them as prescribed to retain your vision."
d. "These symptoms are caused by glaucoma and may indicate a need for an increased dosage of the eyedrops."

C
Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma.

A patient 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 nursing diagnosis is appropriate?

a. Grieving related to current loss of functional vision
b. Anxiety related to the possibility of permanent vision loss
c. Situational low self-esteem related to loss of visual function
d. Risk for falls related to inability to see environmental hazards

B
The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact and the patient is not at a high risk for falls. There is no indication of impaired self-esteem at this time.

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

a. Arrange to include otoscopic examinations for all patients.
b. Administer rubella immunizations to all students at the clinic.
c. Discuss the importance of limiting exposure to very amplified music.
d. Teach patients to regularly irrigate the ear to decrease cerumen impaction.

C
The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Cerumen may need to be regularly removed for older patients, but this is not a routine need for younger adults. Only women of childbearing age who have not been previously vaccinated or exposed to rubella will require immunization. Otoscopic examinations are not necessary for all patients.

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

a. "I may use aspirin or acetaminophen (Tylenol) for pain relief."
b. "I should apply the eardrops to the cotton wick in my ear canal."
c. "I should clean my ear canal daily with a cotton-tipped applicator."
d. "I may use warm compresses to the outside of my ear for comfort."

C
Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful.

A patient with chronic otitis media is scheduled for a tympanoplasty. Before surgery, the nurse teaches the patient that postoperative expectations include

a. keeping the head elevated.
b. the need for prolonged bed rest.
c. avoidance of coughing or blowing the nose.
d. continuous antibiotic irrigation of the ear canal.

C
Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

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

a. The patient has a temperature of 100.6° F.
b. The patient complains of "popping" in the ear.
c. The patient frequently asks the nurse to repeat information.
d. The patient states that the right ear has a feeling of fullness.

A
The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan?

a. Keep the patient's room darkened.
b. Encourage oral fluids to 3000 ml daily.
c. Change the patient's position every 2 hours.
d. Keep the head of the bed elevated 30 degrees.

A
A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Since the patient will be nauseated during an acute attack, fluids are administered intravenously. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort.

The home health nurse observes a patient taking these actions when self-administering eardrops. Which patient action indicates a need for more teaching?

a. The patient leaves the ear wick in place while administering the drops.
b. The patient lies down before and for 2 minutes after administering the drops.
c. The patient gets the eardrops out of the refrigerator just before administering the drops.
d. The patient holds the tip of the dropper 1 cm above the ear while administering the drops.

C
Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate.

When the nurse is admitting a 78-year-old patient, the patient repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take?

a. Overenunciate while speaking.
b. Speak normally but more slowly.
c. Increase the volume when speaking.
d. Use more facial expressions when talking.

B
Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend the nurse.

An older adult patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids?

a. Experiment with volume and hearing ability in a quiet environment initially.
b. Keep the volume low on the hearing aids for the first week while adjusting to them.
c. Add the second hearing aid after making the initial adjustment to the first hearing aid.
d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

A
Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

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

a. Cochlear implants require training in order to receive the full benefit.
b. Cochlear implants are not useful for patients with congenital deafness.
c. Cochlear implants are most helpful as an early intervention for presbycusis.
d. Cochlear implants improve hearing in patients with conductive hearing loss.

A
Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.

Which teaching will the nurse implement for a patient who has just been diagnosed with viral conjunctivitis?

a. Explain the purpose of antiviral eyedrops.
b. Show how to perform eye irrigation safely.
c. Instruct about how to insert soft contact lenses.
d. Demonstrate appropriate hand-washing technique.

D
Hand washing is the major means to prevent the spread of conjunctivitis. Antiviral drops and eye irrigation will not be helpful in shortening the disease process. Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva.

The nurse at the outpatient surgery unit obtains all of this information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information has the most immediate implications for the patient's care?

a. The patient has not eaten anything for 8 hours.
b. The patient takes three antihypertensive medications.
c. The patient gets nauseated with general anesthesia.
d. The patient has had blurred vision for several years.

B
Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Blurred vision is an expected finding with cataracts. Cataract extraction and intraocular lens implantation are done using local anesthesia.

A patient is scheduled for a right cataract extraction and intraocular lens implantation at an ambulatory surgical center in 2 weeks. During the preoperative assessment of the patient in the physician's office, it is most important for the nurse to assess

a. the visual acuity of the patient's left eye.
b. for a white pupil in the patient's right eye.
c. how long that the patient has had the cataract.
d. for a history of reactions to general anesthetics.

A
Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. Cataract surgery is done using local anesthetics rather than general anesthetics. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not impact on the perioperative care.

The nurse notes that nursing assistive personnel (NAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by NAP indicates that the nurse should intervene immediately?

a. NAP raise the side rails on the bed.
b. NAP turn on the patient's television.
c. NAP turn the patient to the right side.
d. NAP place an emesis basin at the bedside.

B
Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate.

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

a. The patient has eye pain rated at a 5 (on a 0-10 scale).
b. The patient has questions about the ordered eyedrops.
c. The patient has poor depth perception when wearing an eye patch.
d. The patient complains that the vision has "not improved very much."

A
Postoperative cataract surgery patients usually experience little or no pain, so pain at a 5 on a 10-point pain level may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring.

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

a. morphine sulfate 4 mg intravenously
b. betaxolol (Betoptic) 1 drop in each eye
c. acetazolamide (Diamox) 250 mg orally
d. mannitol (Osmitrol) 100 mg intravenously

D
The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications also are appropriate for a patient with glaucoma but would not be the first medication administered.

The priority nursing diagnosis for a patient with Ménière's disease who is experiencing an acute attack is

a. risk for falls related to dizziness.
b. impaired verbal communication related to tinnitus.
c. self-care deficit (bathing and dressing) related to vertigo.
d. imbalanced nutrition: less than body requirements related to nausea.

A
All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness.

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management?

a. Statins
b. Vitamins
c. Thrombolytics
d. Anticoagulants

A
Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.

A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and

a. elevate the left leg on a pillow.
b. apply an elastic wrap to the leg.
c. assist the patient in gently exercising the leg.
d. keep the patient in bed in the supine position.

D
The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.

A patient at the clinic says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should

a. attempt to palpate the dorsalis pedis and posterior tibial pulses.
b. check for the presence of tortuous veins bilaterally on the legs.
c. ask about any skin color changes that occur in response to cold.
d. assess for unilateral swelling, redness, and tenderness of either leg.

A
The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to venous thromboembolism (VTE).

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe would expect to find

a. a positive Homans' sign.
b. swollen, dry, scaly ankles.
c. prolonged capillary refill in all the toes.
d. a large amount of drainage from the ulcer.

C
Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the patient's feet is to

a. place the patient in the Trendelenburg position.
b. place two pillows under the calf of the affected leg.
c. elevate the bed at the knee and put pillows under the feet.
d. put one pillow under the thighs and two pillows under the lower legs.

D
The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level

The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says,

a. "I should reduce the amount of green, leafy vegetables that I eat."
b. "I should wear a Medic Alert bracelet stating that I take Coumadin."
c. "I will need to have blood tests routinely to monitor the effects of the Coumadin."
d. "I will check with my health care provider before I begin or stop any medication."

A
Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.

A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that

a. sitting at the work counter, rather than standing, is recommended.
b. compression stockings should be applied before getting out of bed.
c. exercises such as walking or jogging cause recurrence of varicosities.
d. taking one aspirin daily will help prevent clotting around venous valves.

B
Compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended to the patient who had just had sclerotherapy.

Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg?

a. Adequate carbohydrate intake
b. Prophylactic antibiotic therapy
c. Application of compression to the leg
d. Methods of keeping the wound area dry

C
Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment dressings are used to hasten wound healing.

A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. The nurse will anticipate teaching the patient about tests for

a. hypertension.
b. hyperlipidemia.
c. autoimmune disorders.
d. coronary artery disease.

C
Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.

While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information?

a. "When I stand too long, my feet start to swell up."
b. "Sometimes I get tired when I climb a lot of stairs."
c. "My fingers hurt when I go outside in cold weather."
d. "My legs cramp whenever I walk more than a block."

D
Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

When developing a teaching plan for a patient newly diagnosed with peripheral artery disease (PAD), which information should the nurse include?

a. "Exercise only if you do not experience any pain."
b. "It is very important that you stop smoking cigarettes."
c. "Try to keep your legs elevated whenever you are sitting."
d. "Put on support hose early in the day before swelling occurs."

B
Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

When admitting an acutely confused patient with a head injury, which action should the nurse take?

a. Ask family members about the patient's health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data.

A
When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data; this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.

A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, the nurse expects to find

a. spasticity.
b. flaccidity.
c. loss of sensation.
d. hyperactive reflexes.

B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

a. sensation on the left side of the body.
b. voluntary movement on the right side.
c. reasoning and problem-solving abilities.
d. understanding of written and oral language.

D
The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

Propranolol (Inderal), a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for

a. dry mouth.
b. constipation.
c. slowed pulse.
d. urinary retention.

C
Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.

To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse should

a. apply a cotton wisp strand to the cornea.
b. have the patient read a magazine or book.
c. shine a bright light into the patient's pupil.
d. check for unilateral drooping of the eyelids.

A
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.

Neurologic testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which action will the nurse include in the plan of care?

a. Insert an oral airway.
b. Withhold oral fluid or foods.
c. Provide highly seasoned foods.
d. Apply artificial tears every hour.

B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.

The following orders are received for an unconscious patient who has just arrived in the emergency department after a head injury caused by an automobile accident. Which one should the nurse question?

a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes.

B
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but is unable to respond orally to the nurse's questions. The nurse will suspect

a. a brainstem lesion.
b. a temporal lobe lesion.
c. injury to the cerebellum.
d. damage to the frontal lobe.

D
Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to

a. prevent falls.
b. stabilize mood.
c. enhance swallowing ability.
d. improve short-term memory.

A
Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is

a. reflex reaction time.
b. pupil reaction to light.
c. level of consciousness.
d. respiratory rate and rhythm.

D
Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent.

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30

A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?

a. Hematocrit
b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure

D
Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as

a. 9.
b. 11.
c. 13.
d. 15.

B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take?

a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the patient and briefly explain all procedures to them.
c. Call the family's pastor or spiritual advisor to support them while initial care is given.
d. Refer the family members to the hospital counseling service to deal with their anxiety.

B
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take?

a. Have the patient blow the nose.
b. Check the nasal drainage for glucose.
c. Assure the patient that rhinorrhea is normal after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.

B
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?

a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.

B
A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion.

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find

a. judgment changes.
b. expressive aphasia.
c. right-sided weakness.
d. difficulty swallowing.

A
The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

a. The staff nurse suctions the patient every 2 hours.
b. The staff nurse assesses neurologic status every hour.
c. The staff nurse elevates the head of the bed to 30 degrees.
d. The staff nurse administers a mild analgesic before turning the patient.

A
Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

a. Obtain oxygen saturation.
b. Check pupil reaction to light.
c. Palpate the head for hematoma.
d. Assess Glasgow Coma Scale (GCS).

A
Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include

a. prophylactic clipping of cerebral aneurysms.
b. heparin via continuous intravenous infusion.
c. oral administration of low dose aspirin therapy.
d. therapy with tissue plasminogen activator (tPA).

C
The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?

a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided reflexes
d. Difficulty in understanding commands

D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have

a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment.

C
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for

a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.

D
The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to

a. have the patient practice facial and tongue exercises.
b. ask simple questions that the patient can answer with "yes" or "no."
c. develop a list of words that the patient can read and practice reciting.
d. prevent embarrassing the patient by changing the subject if the patient does not respond.

B
Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of

a. impaired physical mobility related to right hemiplegia.
b. risk for injury related to denial of deficits and impulsiveness.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability.

B
Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?

a. Apply an eye patch to the left eye.
b. Approach the patient from the left side.
c. Place objects needed for activities of daily living on the patient's right side.
d. Reassure the patient that the visual deficit will resolve as the stroke progresses.

C
During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care?

a. Provide a wide variety of food choices.
b. Provide oral care before and after meals.
c. Assist the patient to eat with the left hand.
d. Teach the patient the "chin-tuck" technique.

C
Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?

a. Applying intermittent pneumatic compression stockings
b. Assisting to dangle on edge of bed and assess for dizziness
c. Encouraging patient to cough and deep breathe every 4 hours
d. Inserting an oropharyngeal airway to prevent airway obstruction

A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate

A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then

a. order a varied pureed diet.
b. assess the patient's appetite.
c. assist the patient into a chair.
d. offer the patient a sip of juice.

C
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.

A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should

a. use a calm voice to ask the patient to stop the crying behavior.
b. explain to the family that depression is normal following a stroke.
c. have the family members leave the patient alone for a few minutes.
d. teach the family that emotional outbursts are common after strokes.

D
Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

a. The patient's speech is difficult to understand.
b. The patient's blood pressure is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of hypertension.
d. The patient has atrial fibrillation and takes warfarin (Coumadin).

D
The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?

a. Electrocardiogram (ECG)
b. Complete blood count (CBC)
c. Chest radiograph (Chest x-ray)
d. Noncontrast computed tomography (CT) scan

D
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

a. A patient with right-sided weakness who has an infusion of tPA prescribed
b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin)
c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

A
tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

a. Check the respiratory rate.
b. Monitor the blood pressure.
c. Send the patient for a CT scan.
d. Obtain the Glasgow Coma Scale score.

A
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.

While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information?

a. "When I stand too long, my feet start to swell up."
b. "Sometimes I get tired when I climb a lot of stairs."
c. "My fingers hurt when I go outside in cold weather."
d. "My legs cramp whenever I walk more than a block."

D
Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

Identify 2 types of hearing loss

conductive: transmission of sound to inner ear is blocked Sensorineural: damage to 8th cranial nerve

Four nursing interventions for the care of the blind person

Announce presence clearly, call by name, orient carefully to surroundings, walk in front of patient with their hand on your elbow.

Four nursing interventions for the care of the deaf person

Reduce distraction before begginning conversation, look and listen to pt, give pt full attention if he or she is a lip reader, Face pt directly

Who is at risk for stroke?

Persons with hx of HTN, previous TIA's, A-fib or flutter, DM, oral contraceptive use and older adults

Complications of immobility include the potential for thrombus development. State 3 nursing interventions to prevent thrombi

Frequent ROM, Change position every 2 hours, Avoidance of position that decrease venous return.

Define Stroke

A disruption of blood supply to a part of the brain which results in sudden loss of brain function

A client with a dx of stroke presents with sx of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the pt suffered a lesion?

Left

What is the most important indicator of increased ICP?

A change in LOC

What vital sign changes are indicative of increased ICP

Increased BP. Widening pulse pressure. Increased or decreased pulse. Respiratory irregularities. Temperature increase.

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