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ADN 240 Final Knowledge Check HESI Review
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
Terms in this set (211)
A nurse is auscultating a patient's heart sounds and hears an S 4 heart sound. Which condition may be present?
A patient with cardiovascular disease is diagnosed with venous thromboembolism. What assessment finding does the nurse expect?
Asymmetry in limb circumference
While palpating the arteries of a patient with cardiovascular disease, the nurse rates the force of the pulse as weak. How should the nurse document the assessment finding?
A patient with pericarditis is admitted to the hospital. The nurse recognizes that what is the best method of auscultation in this patient?
Ask the patient to sit and lean forward
While assessing a patient for orthopnea, what is an appropriate question for the nurse to ask?
How many pillows do you sleep with at night?
A patient is scheduled for cardiac catheterization. What does the nurse provide to the patient as the primary rationale for the procedure?
Assessing the presence of arterial blockages
A patient's electrocardiogram (ECG) shows a heart rate of 150 beats/minute and a normal P wave preceding each QRS complex. How should the nurse interpret the finding?
A nurse provides education to a patient that is scheduled for exercise testing to evaluate the patient's cardiovascular function. What should the nurse include in the instructions?
Do not take beta blockers 24 hours before the test
The nurse assesses a patient's heart sounds and auscultates the left midclavicular line at the fifth intercostal space (ICS). This is the best location for hearing sounds from which heart valve?
Which property of the cardiac cell aids in responding mechanically to an impulse?
The nurse analyzes a patient's electrocardiogram (ECG) and determines that there are 8 R-R intervals in a span of six seconds. What should the nurse document as the patient's heart rate? Record the answer using a whole number. _____beats/minute.
A nurse is performing a cardiac assessment. How should the nurse assess for jugular venous distention in the patient?
Raise the patient to approximately 45 degrees
The nurse that is monitoring the electrocardiogram (ECG) of a patient with hyperthyroidism observes regular, sawtooth-shaped flutter waves with an atrial rate 250 beats/minute. How should the nurse document this pattern?
A patient reports a new onset of jaw pain. The nurse obtains the following electrocardiogram (ECG) tracing. What action should the nurse take?
Contact the primary health care provider
The nurse recognizes that which cardiac dysrhythmia is life-threatening and necessitates immediate intervention?
A nurse reviewing the recent medical history of a patient with hypoparathyroidism expects to find a history of:
A patient's T3 and T4 levels are decreased, and the TSH (thyroid-stimulating hormone) level is increased. The nurse suspects what condition?
The health care provider was unable to save a patient's parathyroid gland during a radical thyroidectomy. The nurse should consequently pay particular attention to which laboratory value?
The nurse reviews lab values for a patient who underwent thyroidectomy 48 hours ago. Which finding is of most concern?
Decreased serum calcium
The patient experiencing thyrotoxicosis asks the nurse why he or she is being given propranolol. What is the most accurate answer to the patient's question?
To block the sympathetic nervous system response to excess thyroid hormone
A patient with low levels of parathormone in the blood is experiencing frequent muscle spasms in the extremities. Which diet should the nurse suggest to this patient?
Calcium rich diet
Which nursing interventions are appropriate when providing care to a patient that is recovering from a thyroidectomy?
Assessing for tetany, monitoring vital signs, assessing the patient every 2 hours on the first postoperative day
The nurse is caring for a patient diagnosed with a toxic nodular goiter with painless thyroiditis. The nurse suspects that the patient has an autoimmune disease based on what assessment finding?
The nurse assesses the laboratory results for a female patient and finds there are increased levels of follicle-stimulating hormone (FSH). What condition does the nurse suspect this patient is experiencing?
The nurse is caring for a patient with a history of hyperthyroidism who was admitted into the hospital with a kidney infection. It is most important that the nurse notify the health care provider if noting which physical sign or symptom?
Jugular vein distention
Which clinical manifestations does the nurse expect during the assessment of a hospitalized patient experiencing exophthalmos?
Dyspnea, cardiac hypertrophy, bounding rapid pulse
The nurse reviews the laboratory results of a patient and recalls that the normal range of thyroglobulin in females is what?
The patient has been feeling tired lately and has gained weight and reports thickened, dry skin, and increased cold sensitivity even though it is now summer. Which endocrine diagnostic test should be done first ?
Which clinical manifestations does the nurse expect to assess in a patient that is diagnosed with hyperthyroidism?
Weight loss, protrusion of the eyeballs, elevated blood pressure
A patient diagnosed with hyperthyroidism presents with neck nodules that are less than 3 cm in size. Biopsy reveals the nodules are non-malignant. Which treatment does the nurse expect for this patient?
Which medication would the nurse identify as being used to induce abortion?
Which disorder is caused by the deficiency of antidiuretic hormone?
Which term would the nurse use in a report to describe the absence of menstrual periods in a 35-year-old nonpregnant client?
Which hormone would the nurse identify as causing ovulation and promoting lactation?
Which statement is accurate regarding erythropoietin?
An erythropoietin deficiency is associated with renal failure.
Which birth control agent requires administration once every 3 months?
Which hormone is crucial in maintaining the implanted ovum at its site?
Which is a secondary cause of adrenal insufficiency?
Which factor influences acne in adolescent women the most?
Which hormone is formed from cholesterol?
A client is scheduled for an adrenalectomy. Which action would the nurse expect in the plan of care?
Administer parenteral corticosteroids
Which hormone levels do not require monitoring during the administration of menotropins for infertility?
A client with hyperthyroidism is to receive methimazole. Which information would the nurse provide?
Initial improvement will take several weeks.
Which is the etiological factor of nephrogenic diabetes insipidus (DI)?
Which medication would the nurse identify as being used to induce abortion?
Which complication of diabetes can be treated with hyperbaric oxygen?
Diabetic foot ulcers
The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement?
I should look at the condition of my feet daily
The nurse provides education to a patient with newly diagnosed type 1 diabetes mellitus. Which statement made by the patient indicates a need for further instruction?
If I skip breakfast, I can hold my insulin until noon
The nurse is reviewing diabetic self-care management with a patient newly diagnosed with diabetes. The patient is in need of further education when stating to the nurse:
"To toughen my skin so I do not get pressure sores, I should rub my feet down with rubbing alcohol after my bath."
A patient who was recently diagnosed with type 2 diabetes mellitus completed a teaching session about disease management. Which statement by the patient indicates understanding of type 2 diabetes mellitus?
"If I become ill, I will need to check my blood sugar more frequently."
The nurse is evaluating a patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient is considered one of the classic clinical manifestations of diabetes?
After a teaching session with the registered nurse, the newly diagnosed patient with type 1 diabetes mellitus is correct when he or she makes which statement?
I will need to be medicated with insulin for the rest of my life."
The nurse is assigned to care for a patient with type 2 diabetes. To encourage the patient to become an active participant in his or her care, what action should the nurse take?
Assess the patient's understanding of the disease
The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet?
A patient with type 2 diabetes who takes metformin daily to manage blood sugar is scheduled for an intravenous pyelogram (IVP). Which question by the nurse is most important to ask the patient when preparing for the procedure?
When was the last time you took your metformin
What is a risk factor associated with macrovascular complications of diabetes mellitus?
The nurse is teaching a patient with type 2 diabetes about exercise as a method to control blood glucose levels. The nurse knows the patient understands when the patient elicits which exercise plan?
"I will take a brisk 30-minute walk five days per week and do resistance training three times a week."
To determine how well a patient's diabetes mellitus has been controlled over the past two to three months, what assessment parameter should the nurse review?
Which is a symptom of autonomic neuropathy?
The nurse is teaching the caregiver about the manifestations of hypoglycemia in the diabetic patient. What should the caregiver identify as a manifestation of hypoglycemia?
Nervousness and tremors
After a surgical thyroidectomy a client exhibits carpopedal spasm and tremors. The client reports tingling in the fingers and around the mouth. The nurse suspects a deficiency in which mineral?
Which blood glucose levels would the nurse identify as hypoglycemia?
68 mg/dL (3.8 mmol/L)
Which mechanism of action explains how glyburide decreases serum glucose levels?
Stimulates the pancreas to produce insulin
A client with type 1 diabetes asks what causes several brown spots on the skin. What would be the best response by the nurse?
Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."
Which complication associated with type 1 diabetes should the nurse include in the teaching plan for parents of a newly diagnosed child?
Which medication is responsible for neonatal hypoglycemia?
After surgery, total parenteral nutrition (TPN) is instituted via a central venous infusion. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, which action would the nurse take?
Check the serum glucose level.
A child with type 1 diabetes is exhibiting deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. Which blood pH and glucose level would the nurse expect the laboratory tests to reveal?
7.20 and 460 mg/dL (25.5 mmol/L)
Which advice will the nurse give the client to avoid lipodystrophy when self-administering insulin therapy?
Rotate injection sites
During a teaching session about insulin injections, a client asks the nurse, "Why can't I take the insulin in pills instead of taking shots?" How will the nurse respond?
Insulin is destroyed by gastric juices, rendering it ineffective.
A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container?
The local hazardous waste collection site
While obtaining the client's health history, which factor would the nurse identify that predisposes the client to type 2 diabetes?
Being 20 pounds overweight
Why is 15 g of a simple sugar administered when a client with diabetes experiences hypoglycemia?
Increase in blood glucose levels
The nurse is teaching an adolescent newly diagnosed with type 1 diabetes about self-care. Which is the primary long-term goal?
A client with diabetes presents to the emergency department with a 3-hour history of profound weakness and nervousness. According to the spouse, the client became confused shortly after self-administering the morning dose of 10 units of regular insulin and 25 units of NPH insulin. The client had a light breakfast and no additional intake since that time. Which condition would the nurse identify as the likely cause of the client's signs and symptoms?
When the patient is diagnosed with a lung abscess, what should the nurse teach the patient?
Oral antibiotics will be used when the patient and x-ray show evidence of improvement.
For clients experiencing an anaphylactic attack, which medication would the nurse initiate immediately?
The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear?
A child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. Which is the most appropriate nursing intervention?
Stopping the bath and replacing the mask
A client diagnosed with tuberculosis is taking isoniazid. To prevent a food and medication interaction, the nurse will advise the client to avoid which food item?
Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis?
A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client?
It loosens pulmonary secretions
Which complication is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy?
Which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome (FES)?
Which parameter describes the maximum volume of air a client's lungs may contain?
Total lung capacity
The nurse noticed the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client?
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is the priority?
After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition?
"I have abnormal hemoglobin."
A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress?
A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse?
Their gag reflex has returned
Which symptoms are common during the fulminant stage of inhalation of anthrax?
Dyspnea, Diaphoresis, high temperature
A patient is admitted to the hospital with cyanosis, dyspnea, and tachycardia. On examination, the nurse finds that the patient is sweating and has cold, clammy skin. What is the priority nursing action?
Start oxygen therapy
What is the major muscle of respiration?
A nurse is caring for a patient experiencing a chronic cough with a suspected diagnosis of tuberculosis (TB). Which test will be conducted to confirm the diagnosis?
The nurse assesses a patient who is tachypneic and notes a PaO 2 of 56%, a PaCO 2 of 50%, and diminished mental status. The patient's medical history reveals a 40-year history of smoking. Which nursing action is the highest priority?
Initiating the administration of oxygen and continuous pulse oximetry monitoring
A patient undergoes bronchoscopy. Before allowing the patient to begin oral intake of food and fluids, for what should the nurse assess the patient?
Return of gag reflex
The nurse is reviewing the assessment of a newly admitted patient who has an SaO 2reading of 94% on room air. What does this reading indicate?
94% of the hemoglobin attachments for oxygen have oxygen bound to them.
The nurse is assessing a patient in respiratory distress. The nurse knows that what is one of the two clinical methods to determine the efficiency of air transfer in the lung and tissue oxygenation?
After assisting the health care provider with a bedside thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what?
During a routine round on the nursing unit, the nurse notices a patient with an SpO 2 of 70%. The nurse recognizes that the finding indicates what?
The nurse is assessing a patient diagnosed with tuberculosis. Which assessment finding supports this diagnosis?
The nurse is preparing the patient for a diagnostic procedure to remove a mucus plug. The nurse would prepare the patient for which test?
A nurse is interviewing a patient from Asia who reports a chronic cough over the last three months, an evening rise in temperature, and weight loss. The patient will most likely be diagnosed with what?
The patient is calling the clinic complaining of a cough. What assessment should be made first before the nurse advises the patient?
Cough sound, sputum production, and pattern
Which is the term used to describe abnormal breath sounds?
Which diagnostic procedure is used to remove pleural fluid for analysis?
The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every six hours. What should the nurse explain as the best way to prevent oral infection while taking this medication?
Rinse the mouth with water following the second puff of medication.
An asthmatic patient has been prescribed 4 puffs of salmeterol daily. The canister of the meter dose inhaler has 200 puffs. The nurse instructs the patient that the canister will be empty and will need to be replaced in how many days? Record your answer using a whole number. ______days
Which inhaler should the nurse be prepared to administer to the patient at the onset of an asthma attack?
A patient presents to the emergency department with sudden-onset wheezing and coughing with progressive respiratory distress. What condition or diagnosis does the nurse recognize?
An Asthma attack
In which position is it most appropriate for the nurse to place a patient experiencing an asthma exacerbation?
A patient is prescribed an inhaler for treatment of asthma. The medication canister contains 200 puffs, scheduled to last for 25 days. The nurse should instruct the patient to inhale how many puffs per day to receive the prescribed amount?
The nurse is evaluating an asthmatic patient's knowledge of self-care. Which statement by the patient indicates an adequate understanding of the instructions given?
"I will keep my rescue inhaler with me at all times."
A patient with asthma experiences anaphylaxis. Which medication should the nurse prepare to administer?
What instruction should the nurse give to a patient with asthma who has received a prescription for albuterol and ipratropium nebulization?
After the treatment, cough effectively.
The nurse determines that the patient has experienced the full benefits of medication therapy with ipratropium when which assessment finding is noted?
Clear lung sounds
The patient has a prescription for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/mL. Calculate how many mL the nurse should use to prepare the patient's dose. ______mL
The nurse is explaining the pathophysiology of asthma to a patient. Which is the most appropriate explanation?
"Inflammation causes bronchoconstriction, hyperreactivity, and edema of the airways."
During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change?
Narrowing of the airway
A patient with asthma has a body temperature of 102° F and produces purulent sputum. The nurse anticipates that which drug will be prescribed?
The nurse provides education to a patient who is prescribed a metered-dose inhaler. Which actions taken by the patient indicate the need for further teaching?
Inhales more than one puff with each inspiration, Does not shake the metered-dose inhaler before use
Which nursing intervention would the nurse direct toward a child admitted for acute glomerulonephritis?
Which part of the kidney senses changes in blood pressure?
A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP), has an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor?
Which type of cytokine is used to treat anemia secondary to chronic kidney disease?
Which term would the nurse document in the client's medical record after observing reduced urinary output?
When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation?
A client is taking fertility medications for the first time. Which adverse effect of the medication would the nurse inform the client about?
For which additional defect would the nurse assess an infant with exstrophy of the bladder?
Pubic bone malformation
Identify the type of hypersensitivity reaction associated with systemic lupus erythematosus (SLE).
A client who takes rifampin tells the nurse, "My urine looks orange." Which action would the nurse take?
Explain that this is expected
A client with Hodgkin's disease adds doxorubicin to current therapy. Which advice will the nurse provide about this medication?
Expect urine to turn red for a few days after taking this medication.
A health care provider prescribes furosemide for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in which part of the renal system?
Loope of henle
Which ovulation stimulant would the nurse identify as being derived from the urine of postmenopausal women?
A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action will the nurse take next?
Notify the health care provider that the potassium level is below normal.
A client diagnosed with invasive cancer of the bladder has brachytherapy scheduled. Which successful therapy outcome would the nurse expect with this client?
Shrinkage of the tumor when scanned
The nurse instructs a patient with hyperphosphatemia to avoid what food item?
The nurse recognizes that which recommendation is appropriate for a patient with chronic kidney disease (CKD)?
Take phosphate binders with meals.
The patient has undergone renal biopsy. What should the nurse do after the procedure?
Apply pressure dressing and lay the patient on the unaffected side.
A patient is instructed to have a quantitative urine protein test done. What should the nurse advise this patient about collecting the urine sample?
Collect all urine for 24 hours.
Aldosterone acts on the distal tubule of the kidney to do what?
Cause the excretion of potassium
Assessment findings of a patient with chronic kidney failure include a glomerular filtration rate (GFR) of 10 mL/min, numbness and burning sensation in the legs, and a blood urea nitrogen level (BUN) of 26 mg/dL. The nurse anticipates that which intervention will be included on the patient's plan of care?
Make a referral for dialysis.
The nurse should monitor for which adverse effect of erythropoietin in patients with kidney failure?
The nurse identifies that which drug should be used with caution in a patient with renal failure?
The nurse is planning an educational course on risk factors for chronic kidney disease. Which factors should the nurse identify as nonmodifiable risk factors?
Age greater than 60, family history of chronic kidney disease
The nurse is teaching a patient with chronic kidney disease to avoid foods high in potassium. Which high-potassium foods should the patient avoid?
Bananas, oranges, and potatoes
The nurse is teaching a patient with chronic kidney disease about restricting phosphorous in the diet. The nurse determines the teaching was effective when the patient correctly identifies which examples of foods as high in phosphorous?
Milk, cheese, steak, pudding
A patient is scheduled for an intravenous pyelogram (IVP). What is the priority action by the nurse to prepare the patient for the procedure?
Administer a cathartic or enema
The nurse is preparing to palpate a patient's kidneys during an assessment. How should the nurse position the patient for this assessment?
When the patient reports acute, severe, renal colic pain in the lower abdomen, the nurse knows that the patient is most likely to have an obstruction at which area?
Which effect of aging on the urinary system is most likely to affect the action of bumetanide?
Decreased function of the loop of Henle
Which sexually transmitted infection is caused by human papillomavirus?
Which clinical manifestation is associated with cellulitis?
Which statements regarding acne are correct?
Acne may be caused by stress., Family history could be a reason for acne, Propionibacterium acnes causes acne, Acne is commonly found on the face, chest, upper back, and neck
How would the nurse describe the exudate characteristic of a serosanguineous wound?
Blood-tinged amber fluid
Which vaccine is used to prevent human papilloma virus infection?
The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care?
For which client illness would airborne precautions be implemented?
Which organism would the nurse explain was responsible for a client's recent diagnosis of malaria?
Which organism would the nurse teach immigrants is the cause of smallpox?
Which type of hepatitis virus spreads through contaminated food and water?
Hepatits A Virus
Which prescribed medication will the nurse administer to the client with pertussis?
Which sexually transmitted infection causes condylomata acuminate?
Human Papillomavirus (HPV)
A client diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I'm not worried because they have a cure for AIDS." Which response would the nurse use?
"There is no cure for AIDS, but there are medications that can slow down the virus."
Which term describes the practice of placing clients with the same infection in a semi-private room?
Which criteria would the nurse consider when determining if an infection is a health care-associated infection?
Occurred in conjunction with treatment for an illness
What bacteria live in the large intestine and act to protect the body by preventing the overgrowth of other microorganisms?
The nurse is to administer a first dose of cephalexin to a patient with an upper respiratory infection. What information is of the highest priority before administering the cephalexin?
No allergy to penicillin
A patient admitted to the hospital with cirrhosis of the liver suddenly starts vomiting blood. What is the priority action that the nurse should take in this situation?
Stabilize the patient and manage the airway.
Which is a microorganism capable of causing disease?
The nurse is preparing to disconnect IV fluid tubing from the access port so the patient can ambulate to the bathroom. What will the nurse wear to prevent the spread of pathogens?
Which bacteria is considered normal flora in the large intestine?
A primary health care provider advises against prescribing an antibiotic to a patient with a severe cold, sore throat, and running nose. The patient tells the nurse, "I really want an antibiotic to make this cold go away." What is the best response by the nurse?
"An antibiotic is ineffective against a cold or flu."
A patient with pneumococcal pneumonia is prescribed ceftriaxone for 10 days. During a follow-up visit, the patient reports to the nurse, "I stopped the medication after taking it for five days because I felt better." What is the best nursing response?
Explain the importance of completing the planned medication therapy.
The nurse is providing education to parents to prepare their children for school. Which infection is preventable with vaccines?
A patient with human immunodeficiency virus (HIV) taking antiretroviral therapy reports they are starting to feel like they did before starting the therapy. What test should the nurse prepare the patient for?
The nurse recalls that hepatic coma results primarily from accumulation of which substance in the blood?
A patient with human immunodeficiency virus (HIV) is educated about health promotion activities. What should the nurse inform the patient the importance of these activities is?
Delaying disease progression
The nurse provides discharge instructions to a patient with newly diagnosed cirrhosis. Which statement made by the patient indicates the need for further teaching?
I can eat anything that appeals to me.
The patient with advanced cirrhosis asks why his or her skin is so yellow. The nurse's response is based on what knowledge?
Jaundice results from the body's inability to conjugate and excrete bilirubin.
A patient has developed West Nile virus after being bitten by a mosquito. What type of infection does the nurse recognize the patient has contracted?
A client with hemiparesis voices a reluctance to use a cane. Which rationale would the nurse use to explain the cane's purpose to the client?
Maintain balance to improve stability
Which medication would the nurse identify as a potential cause for the formation of abnormally small eyes in the newborn if used during pregnancy?
Which key feature is associated with a stage 2 pressure ulcer?
Presence of nonintact skin
An adult client with low-functioning Down syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining this client's level of pain?
Using the Wong-Baker FACES Pain Rating Scale
Which is the middle layer of the eyeball?
A 2-year-old toddler has hearing loss caused by recurrent otitis media. Which treatment would the nurse anticipate that the practitioner will recommend?
After a cerebrovascular accident (CVA, also known as "brain attack"), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain?
Which structure lies inside and parallel to the sclera?
Damage to which cranial nerve may lead to decreased olfactory acuity?
Cranial nerve 1
Which medication may cause photophobia as an adverse effect?
After a discectomy and fusion surgery, the client wants to attempt walking with assistance for the first time. Upon rising to a standing position, the client reports feeling faint and light headed. Which action would the assisting nurse have the client do upon hearing the client's concern?
Have the client sit on the edge of the bed so the nurse can hold the client upright.
Which definition of photophobia is accurate?
Persistent abnormal intolerance to light
A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." Which response would the nurse provide?
The medication may need to be discontinued. Come to the clinic this afternoon."
An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury?
During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess?
The nurse is assessing an older adult patient who just has been transferred to a long-term care facility. Which question will best allow the nurse to assess the woman for the presence of presbycusis?
"Have you noticed any change in your hearing in recent months and years?"
A patient comes to a clinic with hairline fluid level in the tympanum. There are yellowish bubbles above the fluid level. The nurse recognizes that what condition is most likely present?
Serous otitis media
While interviewing a patient, the nurse finds that the patient keeps the head skewed while talking. The patient could be experiencing what condition?
A nurse is assessing a patient with hearing loss that gives a history of taking various medications in the past few years. Which drugs taken by the patient may be ototoxic?
Aspirin, antibiotics, Antimalarial drugs
While completing a health history, the nurse learns that a patient has symptoms of tinnitis. Which follow-up question should the nurse ask?
"Do you routinely take aspirin or have you increased your aspirin intake lately?"
The nurse is performing an assessment to determine function of the retina and optic nerve. What tool should the nurse prepare to use for this test?
When examining the patient's ear with an otoscope, there is discharge in the canal and the patient reports pain with the examination. For what should the nurse next assess the patient?
An older adult patient reports not being able to hear very well. What should the nurse do first to determine the cause of the hearing loss?
Look for cerumen in the ear.
The nurse is assessing a patient's distance and near visual acuity. What test should the nurse perform?
A nurse is assessing a patient with chronic tinnitus. Which question is appropriate to ask when exploring the patient's sleep habits?
"Is your sleep disturbed by ringing in your ears?"
The nurse is assessing an adult patient's external ear canal and tympanum. How should the nurse proceed?
Gently pull the auricle up and backward to straighten the canal
Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred?
The nurse is educating a patient about the importance of wearing sunglasses when exposed to ultraviolet light. Which abnormality is associated with the chronic exposure of the eye lens to ultraviolet light?
A patient comes to the clinic for an ophthalmic checkup. A nurse performs an assessment of visual acuity using a Snellen chart. The patient should be positioned how many feet away from the Snellen chart?
20 feet away
A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect to see in this patient?
Drooping of the upper lid margin in one or both eyes
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