L2-10-E5

Question 1

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient’s discharge planning?

a. The mechanisms of the inflammatory response
b. Basic infection control techniques
c. The importance of wearing a face mask in public
d. Limiting contact with the general population

Answer 1

b. Basic infection control techniques

The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

Question 2

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child’s growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition?

a. Primary immunodeficiency
b. Secondary immunodeficiency
c. Cancer
d. Autoimmunity

Answer 2

a. Primary immunodeficiency

Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

Question 3

The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition?

a. His immune system is functioning properly.
b. He is properly vaccinated.
c. He has an infection.
d. The suppressor T-cells in his body are activated.

Answer 3

a. His immune system is functioning properly.

Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body’s response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

Question 4

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement?

a. “My body will treat the new kidney like my original kidney.”
b. “I will have to make sure that I avoid being around people.”
c. “The medications that I take will help prevent my body from attacking my new kidney.”
d. “My body will only have a problem with my new kidney if the donor is not directly related to me.”

Answer 4

c. “The medications that I take will help prevent my body from attacking my new kidney.”

Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don’t have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

Question 5

The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient’s respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition?

a. Suppressed immune response
b. Hyperimmune response
c. Allergic reaction
d. Anaphylactic reaction

Answer 5

d. Anaphylactic reaction

The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

Question 6

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient?

a. Eradicate the disease
b. Enhance immune response
c. Control inflammation
d. Manage pain

Answer 6

c. Control inflammation

Medications for RA are intended to control the inflammation that results from the body’s hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

Question 7

The parents of a newborn question the nurse about the need for vaccinations: “Why does our baby need all those shots? He’s so small, and they have to cause him pain.” The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)

a. Are only required for infants
b. Are part of primary prevention for system disorders
c. Prevent the child from getting childhood diseases
d. Help protect individuals and communities
e. Are risk free
f. Are recommended by the Centers for Disease Control and Prevention (CDC)

Answer 7

b. Are part of primary prevention for system disorders
d. Help protect individuals and communities
f. Are recommended by the Centers for Disease Control and Prevention (CDC)

Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won’t get the disease, but it decreases the potential to contract the illness. No medication is risk free.

Question 8

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?

a. Plasmapheresis eliminates eosinophils and basophils from blood.
b. Plasmapheresis decreases the damage to organs from T lymphocytes.
c. Plasmapheresis removes antibody-antigen complexes from circulation.
d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.

Answer 8

c. Plasmapheresis removes antibody-antigen complexes from circulation.

Plasmapheresis is used in SLE to remove antibodies, antibody–antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

Question 9

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation?

a. Shortness of breath
b. High blood pressure
c. Transfusion reaction
d. Extremity numbness

Answer 9

d. Extremity numbness

Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

Question 10

Which patient should the nurse assess first?

a. Patient with urticaria after receiving an IV antibiotic
b. Patient who is sneezing after subcutaneous immunotherapy
c. Patient who has graft-versus-host disease and severe diarrhea
d. Patient with multiple chemical sensitivities who has muscle stiffness

Answer 10

b. Patient who is sneezing after subcutaneous immunotherapy

Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

Question 11

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash?

a. The donor T cells are attacking the patient’s skin cells.
b. The patient needs treatment to prevent hyperacute rejection.
c. The patient’s antibodies are rejecting the donor bone marrow.
d. The patient is experiencing a delayed hypersensitivity reaction.

Answer 11

a. The donor T cells are attacking the patient’s skin cells.

The patient’s history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient’s tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.

Question 12

A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

a. Take this medication on an empty stomach.
b. Take this medication with a full glass of water.
c. You may have vivid and bizarre dreams as a side effect.
d. Continue to use contraception while taking this medication.

Answer 12

d. Continue to use contraception while taking this medication.

To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in patients who may be or may become pregnant. The other information is also accurate, but it does not directly prevent harm. The medication should be taken on an empty stomach with water and patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.

Question 13

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

a. CD4+ cell count trajectory
b. HIV genotype and phenotype
c. Patient’s tolerance for potential medication side effects
d. Patient’s ability to follow a complex medication regimen

Answer 13

d. Patient’s ability to follow a complex medication regimen

Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

Question 14

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

a. Patient who is currently HIV negative but has unprotected sex with multiple partners
b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/μL
c. HIV-positive patient with a CD4+ count of 160/μL who drinks a fifth of whiskey daily
d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

Answer 14

d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.

Question 15

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?

a. Instruct the patient to apply ice to the neck.
b. Explain to the patient that this is an expected finding.
c. Request that an antibiotic be prescribed for the patient.
d. Advise the patient that this indicates influenza infection.

Answer 15

b. Explain to the patient that this is an expected finding.

Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu. Ice will not decrease the swelling in persistent generalized lymphadenopathy

Question 16

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?

a. Age
b. Lifestyle
c. Symptoms
d. Sexual orientation

Answer 16

a. Age

The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

Question 17

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

a. “Clean drug injection equipment before each use.”
b. “Ask those who share equipment to be tested for HIV.”
c. “Consider participating in a needle-exchange program.”
d. “Avoid sexual intercourse when using injectable drugs.”

Answer 17

c. “Consider participating in a needle-exchange program.”

Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

Question 18

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

a. Give the patient detailed information about possible medication side effects.
b. Remind the patient of the importance of taking the medications as scheduled.
c. Encourage the patient to join a support group for students who are HIV positive.
d. Check the patient’s class schedule to help decide when the drugs should be taken.

Answer 18

d. Check the patient’s class schedule to help decide when the drugs should be taken.

The best approach to improve adherence is to learn about important activities in the patient’s life and adjust the ART around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing the ART to the patient’s schedule.

Question 19

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

a. The patient will be free from injury.
b. The patient will receive immunizations.
c. The patient will have adequate oxygenation.
d. The patient will maintain intact perineal skin.

Answer 19

d. The patient will maintain intact perineal skin.

The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza) associated with HIV infection.

Question 20

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient?

a. Review foods that are higher in protein.
b. Teach about the benefits of daily exercise.
c. Discuss a change in antiretroviral therapy.
d. Talk about treatment with antifungal agents.

Answer 20

c. Discuss a change in antiretroviral therapy.

A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

Question 21

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?

a. Nystatin tablet
b. Oral acyclovir (Zovirax)
c. Oral saquinavir (Invirase)
d. Aerosolized pentamidine (NebuPent)

Answer 21

c. Oral saquinavir (Invirase)

It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

Question 22

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

a. Viral loading test
b. Enzyme immunoassay
c. Rapid HIV antibody testing
d. Immunofluorescence assay

Answer 22

a. Viral loading test

The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

Question 23

The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

a. The patient complains of feeling “constantly tired.”
b. The patient can’t explain the effects of indinavir (Crixivan).
c. The patient reports missing some doses of zidovudine (AZT).
d. The patient reports having no side effects from the medications.

Answer 23

c. The patient reports missing some doses of zidovudine (AZT).

Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of AZT.

Question 24

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/μL and an undetectable viral load. What is the priority nursing intervention at this time?

a. Encourage adequate nutrition, exercise, and sleep.
b. Teach about the side effects of antiretroviral agents.
c. Explain opportunistic infections and antibiotic prophylaxis.
d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

Answer 24

a. Encourage adequate nutrition, exercise, and sleep.

The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

Question 25

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose rapid HIV-antibody test is positive b. Patient whose latest CD4+ count has dropped to 250/μL c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs

Answer 25

c. Patient who has had 10 liquid stools in the last 24 hours The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.

Question 26

An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching? a. Many drugs interact with antiretroviral medications. b. HIV infections progress more rapidly in older adults. c. Less frequent CD4+ level monitoring is needed in older adults. d. Hospice care is available for patients with terminal HIV infection.

Answer 26

a. Many drugs interact with antiretroviral medications. The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease.

Question 27

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient how to dispose of tissues with respiratory secretions. b. Stock the patient’s room with the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient’s family members the reason for the use of airborne precautions.

Answer 27

b. Stock the patient’s room with the necessary personal protective equipment. A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

Question 28

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

Answer 28

c. Prevention of HIV transmission between sexual partners Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

Question 29

The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

Answer 29

a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.

Question 30

A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

Answer 30

b. blood pressure. Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

Question 31

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse’s teaching about the condition? a. “I will exercise even if I am tired.” b. “I will use sunscreen when I am outside.” c. “I should avoid nonsteroidal antiinflammatory drugs.” d. “I should take birth control pills to avoid getting pregnant.”

Answer 31

b. “I will use sunscreen when I am outside.” Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

Question 32

A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, “I never leave my house because I hate the way I look.” The nurse will plan interventions with the patient to address the nursing diagnosis of a. social isolation. b. activity intolerance. c. impaired skin integrity. d. impaired social interaction.

Answer 32

a. social isolation. The patient’s statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

Question 33

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

Answer 33

c. Anti-Smith antibody (Anti-Sm) The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

Question 34

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Naproxen (Aleve) 200 mg BID. d. Famotidine (Pepcid) 20 mg daily.

Answer 34

b. Administer varicella vaccine. Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

Question 35

Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

Answer 35

b. Elevated blood urea nitrogen (BUN) Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.

Question 36

A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. The safety priority for the patient is addressing the a. acute pain. b. risk for aspiration. c. disturbed visual perception. d. risk for impaired skin integrity.

Answer 36

b. risk for aspiration. The patient’s vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient’s airway.

Question 37

A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding by the nurse is important to report to the health care provider? a. The patient has painful hematuria. b. Acne is noted on the patient’s face. c. Fasting blood glucose is 112 mg/dL. d. The patient has an increased appetite.

Answer 37

a. The patient has painful hematuria. Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

Question 38

After the nurse has taught a 28-yr-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. “I will need to stop drinking so much coffee and soda.” b. “I am going to join a soccer team to get more exercise.” c. “I will call the doctor every time my symptoms get worse.” d. “I should avoid using over-the-counter medications for pain.”

Answer 38

a. “I will need to stop drinking so much coffee and soda.” ANS: A Dietitians frequently suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management.

Question 39

Which information will the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management? a. Symptoms usually progress as patients become older. b. A gradual increase in daily exercise may help decrease fatigue. c. Avoid use of over-the-counter antihistamines or decongestants. d. A low-residue, low-fiber diet will reduce any abdominal distention.

Answer 39

b. A gradual increase in daily exercise may help decrease fatigue. A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.

Question 40

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)? a. Sleep disturbances b. Multiple tender points c. Cardiac palpitations and dizziness d. Multijoint inflammation and swelling e. Widespread bilateral, burning musculoskeletal pain

Answer 40

a. Sleep disturbances b. Multiple tender points e. Widespread bilateral, burning musculoskeletal pain These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.

Question 41

An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient’s daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

Answer 41

d. The patient has recently lost her spouse and needed to move in with her daughter. The stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in older people. Caring for children will increase the patient's sense of worth. Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patient's daughter may have added stress due to working, but this should not directly affect the patient.

Question 42

A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Administer the PRN sedative medication every 4 hours. c. Suggest the use of a home caregiver to the patient's family. d. Plan to reinforce and repeat teaching about diabetes management.

Answer 42

d. Plan to reinforce and repeat teaching about diabetes management. Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary information for self-management.

Question 43

A diabetic patient who is hospitalized tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.” Which response by the nurse is appropriate? a. “It is probably just coincidental that your blood sugar is high when you are ill.” b. “Stressors such as illness cause the release of hormones that increase blood sugar.” c. “Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times.” d. “Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level.”

Answer 43

b. “Stressors such as illness cause the release of hormones that increase blood sugar.” The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

Question 44

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30 to 60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

Answer 44

c. Slow and deepen breathing via use of a positive, repeated word. The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson's relaxation response) will counter the sympathetic nervous system's arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

Question 45

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional beta-endorphins.

Answer 45

a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery's effectiveness.

Question 46

A patient tells the nurse, “I'm told that I should reduce the stress in my life, but I have no idea where to start.” Which would be the best initial nursing response? a. “Why not start by learning to meditate? That technique will cover everything.” b. “In cases like yours, physical exercise works to elevate mood and reduce anxiety.” c. “Reading about stress and how to manage it might be a good place to start.” d. “Let’s talk about what is going on in your life and then look at possible options.”

Answer 46

d. “Let’s talk about what is going on in your life and then look at possible options.” In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

Question 47

A patient tells the nurse “My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking.” Which response would be in keeping with the doctor's recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling

Answer 47

a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient's manner of thinking.

Question 48

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

Answer 48

c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

Question 49

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

Answer 49

b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.

Question 50

The nurse is working with a patient who recently lost her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.) a. Notify the provider to evaluate for antidepressant therapy. b. Suggest that the patient consider a support group for widows. c. Suggest that the patient learn stress reduction breathing exercises. d. Suggest that the patient take prescribed anti-anxiety medications. e. Assist the patient in identifying support systems. f. Notify the provider to evaluate the need for anti-anxiety medications.

Answer 50

b. Suggest that the patient consider a support group for widows. c. Suggest that the patient learn stress reduction breathing exercises. e. Assist the patient in identifying support systems. Stress prevention management involves counseling, education, and implementation of techniques to manage problem-oriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated for patients with known stressors unless the stress is prolonged or the patient has ineffective coping mechanisms.

Question 51

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is known as which of the following? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet

Answer 51

a. Identifying the cause of fear Identifying the cause of a negative perception is the first step in restructuring how a patient perceives a stressor, also called cognitive restructuring. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

Question 52

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families

Answer 52

c. Identifying a confidant to share feelings Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars. Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

Question 53

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

Answer 53

c. Increased risk for suicide Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

Question 54

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member's home. d. Ask social services to assess what the patient's needs will be after discharge to home.

Answer 54

a. Ask if there is another family member who can help at home while the patient is in the hospital. The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability to provide the care by another, and distance of the transfer. Assessing the patient's needs after discharge does not address the immediate need to provide care for the disabled family person.

Question 55

After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

Answer 55

c. Have training sessions to help the staff understand their new responsibilities. Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.

Question 56

The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. “This tool will let us compare your stress to other patients in the hospital.” b. “This tool is short because it only measures the negative stressors you are experiencing.” c. “You will need to ask your parents about stressors you had as a child to complete this tool.” d. “This tool will help assess recent positive and negative events you are experiencing.”

Answer 56

d. “This tool will help assess recent positive and negative events you are experiencing.” Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed. Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

Question 57

The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment? (Select all that apply.) a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes d. Age and height e. Temperature

Answer 57

a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes Stressors are subjective based on patient perception and assessment of stressors as part of a patient history. Stressors trigger coping behaviors that can include negative uses of drugs and alcohol and appetite changes that affect weight. Age, height, and temperature are not typically altered with coping, although pulse, respiratory rate, and blood pressure may be affected.

Question 58

An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate? a. Start an IV line to administer antihypertensive medications. b. Recheck the blood pressure after the patient has been assessed. c. Discuss the need for hospital admission to control blood pressure. d. Teach the patient about the stroke risk associated with uncontrolled hypertension.

Answer 58

b. Recheck the blood pressure after the patient has been assessed. When a patient experiences an acute stressor, the BP increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient’s usual blood pressure. Elevated BP that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.

Question 59

A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Focus teaching on preventing postoperative complications. c. Try to calm the patient before repeating any information about the surgery. d. Encourage the patient to combine the hysterectomy with surgery for bladder repair.

Answer 59

c. Try to calm the patient before repeating any information about the surgery. Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken or discontinued before surgery, and so on. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy.

Question 60

An adult patient who is hospitalized after a motorcycle crash tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care? a. Anxiety b. Defensive coping c. Ineffective denial d. Risk prone health behavior

Answer 60

a. Anxiety The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient.

Question 61

A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure? a. Yoga stretching b. Guided imagery c. Relaxation breathing d. Mindfulness meditation

Answer 61

c. Relaxation breathing Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagery require more time to practice and learn.

Question 62

A patient who has frequent migraines tells the nurse, “My life feels chaotic and out of my control. I could not manage if anything else happens.” Which response should the nurse make initially? a. “Regular exercise may get your mind off the pain.” b. “Guided imagery can be helpful in regaining control.” c. “Tell me more about how your life has been recently.” d. “Your previous coping resources can be helpful to you now.”

Answer 62

c. “Tell me more about how your life has been recently.” The nurse’s initial strategy should be further assessment of the stressors in the patient’s life. Exercise, guided imagery, or understanding how to use coping strategies that worked in the past may be of assistance to the patient, but more assessment is needed before the nurse can determine this.

Question 63

A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse knows that this is a painful procedure and wants to try providing music to help the patient relax. Which action is best for the nurse to take? a. Use music composed by Mozart. b. Play music that does not have words. c. Ask the patient about music preferences. d. Select music that has 60 to 80 beats/minute.

Answer 63

c. Ask the patient about music preferences. Although music with 60 to 80 beats/min, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important.

Question 64

The nurse teaches a patient who is experiencing stress at work how to use imagery as a relaxation technique. Which statement by the nurse would be appropriate? a. “Think of a place where you feel peaceful and comfortable.” b. “Place the stress in your life into an image that you can destroy.” c. “Repeatedly visualize yourself experiencing the distress in your workplace.” d. “Bring what you hear and sense in your work environment into your image.”

Answer 64

a. “Think of a place where you feel peaceful and comfortable.” Imagery is the use of one’s mind to generate images that have a calming effect on the body. When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The goal is to offer a relaxing retreat from the actual work environment. Imagery that is not intended for relaxation purposes can target a disease, problem, or stressor.

Question 65

An obese female patient who had enjoyed active outdoor activities is stressed because osteoarthritis in her hips now limits her activity. Which action by the nurse will best assist the patient to cope with this situation? a. Have the patient practice frequent relaxation breathing. b. Ask the patient what outdoor activities she misses the most. c. Teach the patient to use imagery for reducing pain and stress. d. Encourage the patient to consider weight loss to improve symptoms.

Answer 65

d. Encourage the patient to consider weight loss to improve symptoms. For problems that can be changed or controlled, problem-focused coping strategies, such as encouraging the patient to lose weight, are most helpful. The other strategies also may assist the patient in coping with her problem, but they will not be as helpful as a problem-focused strategy.

Question 66

A hospitalized patient with diabetes tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating.” Which response by the nurse is accurate? a. “The liver is not able to metabolize glucose as well during stressful times.” b. “Your diet at the hospital is the most likely cause of the increased glucose.” c. “The stress of illness causes release of hormones that increase blood glucose.” d. “It is probably coincidental that your blood glucose is higher when you are ill.”

Answer 66

c. “The stress of illness causes release of hormones that increase blood glucose.” The release of cortisol, epinephrine, and norepinephrine increase blood glucose levels. The increase in blood glucose is not coincidental. The liver does not control blood glucose. A patient with diabetes who is hospitalized will be on an appropriate diet to help control blood glucose.

Question 67

A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 mm Hg and a blood glucose level of 190 mg/dL. What patient information may indicate that additional intervention by the nurse is needed? a. The patient states that he takes his prescribed antihypertensive medications daily. b. The patient states that both of his parents have high blood pressure and diabetes. c. The patient indicates that he does blood glucose monitoring several times each day. d. The patient reports that he and his wife are disputing custody of their 8-yr-old son.

Answer 67

d. The patient reports that he and his wife are disputing custody of their 8-yr-old son. The increase in blood pressure and glucose levels possibly suggests that stress caused by his divorce and custody battle may be adversely affecting his health. The nurse should assess this further and develop an appropriate plan to assist the patient in decreasing his stress. Although he has been very compliant with his treatment plan in the past, the nurse should assess whether the stress in his life is interfering with his management of his health problems. The family history will not necessarily explain why he has had changes in his blood pressure and glucose levels.

Question 68

A patient who is taking antiretroviral medication to control human immunodeficiency virus (HIV) infection tells the nurse about feeling mildly depressed and anxious. Which additional information about the patient is most important to communicate to the health care provider? a. The patient takes vitamin supplements and St. John’s wort. b. The patient recently experienced the death of a close friend. c. The patient’s blood pressure has increased to 152/88 mm Hg. d. The patient expresses anxiety about whether the drugs are effective.

Answer 68

a. The patient takes vitamin supplements and St. John’s wort. St. John’s wort interferes with metabolism of medications that use the cytochrome P450 enzyme system, including many HIV medications. The health care provider will need to check for toxicity caused by the drug interactions. Teaching is needed about drug interactions. The other information will also be reported but does not have immediate serious implications for the patient’s health.

Question 69

A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. What actions should the nurse take based on knowledge of the physiologic stress reactions that may occur in this patient (select all that apply)? a. Assess for bradycardia. b. Observe for decreased appetite. c. Ask about epigastric discomfort. d. Monitor for decreased respiratory rate. e. Check for elevated blood glucose levels.

Answer 69

b. Observe for decreased appetite. c. Ask about epigastric discomfort. e. Check for elevated blood glucose levels. The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates.

Question 70

In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions? a. Restorative care factors b. Strong financial resource factors c. Maturational and situational factors d. Immaturity and intelligence factors

Answer 70

c. Maturational and situational factors Maturational factors and situational factors can affect people differently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong financial resources, or is immature or intelligent.

Question 71

A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart? a. General adaptation syndrome b. Post-traumatic stress disorder c. Acute stress disorder d. Alarm reaction

Answer 71

b. Post-traumatic stress disorder Post-traumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional detachment and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Acute stress disorder is a similar diagnosis that differs from PTSD in duration of symptoms. Alarm reaction involves physiological events such as increased activation of the sympathetic nervous system that would have occurred at the time of the sexual assault.

Question 72

The nurse teaches stress-reduction and relaxation training to a health education group of patients after cardiac bypass surgery. Which level of intervention is the nurse using? a. Primary b. Secondary c. Tertiary d. Quad

Answer 72

c. Tertiary Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. At the primary level of prevention, you direct nursing activities to identifying individuals and populations who are possibly at risk for stress. Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm. Quad level does not exist.

Question 73

A nurse is teaching guided imagery to a prenatal class. Which technique did the nurse describe? a. Singing b. Massaging back c. Listening to music d. Using sensory peaceful words

Answer 73

d. Using sensory peaceful words Guided imagery is used as a means to create a relaxed state through the person’s imagination, often using sensory words. Imagination allows the person to create a soothing and peaceful environment. Singing, back massage, and listening to music are other types of stress management techniques.

Question 74

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating, “No way, I’m not crazy.” What is the nurse’s best response? a. “Many times disasters can create mental health problems, so you really should participate with your family.” b. “Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.” c. “Don’t worry now. The psychiatrists are well trained to help.” d. “This will help your family communicate better.”

Answer 74

b. “Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.” Crisis intervention is a type of brief therapy that is more directive than traditional psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The other options do not properly reassure the patient and build trust. Giving advice in the form of “you really should participate” is inappropriate. “Don’t worry now” is false reassurance. While crisis intervention may help families communicate better, the goal is to return to pre-crisis level of functioning; family therapy will focus on helping families communicate better.

Question 75

A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care? a. Identity issues b. Self-esteem issues c. Physical appearance d. Major changing life events

Answer 75

b. Self-esteem issues Preadolescents experience stress related to self-esteem issues, changing family structure as a result of divorce or death of a parent, or hospitalizations. Adolescent stressors include identity issues with peer groups and separation from their families. Children identify stressors related to physical appearance, families, friends, and school. Adult stressors centralize around major changes in life circumstances.

Question 76

A nurse is caring for a patient with stress and is in the evaluation stage of the critical thinking model. Which actions will the nurse take? a. Select nursing interventions and promote patient’s adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions and achieve expected outcomes. d. Reassess patient’s stress-related symptoms and compare with expected outcomes.

Answer 76

d. Reassess patient’s stress-related symptoms and compare with expected outcomes. During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process.

Question 77

An adult male reports new-onset, seizure-like activity. An EEG and a neurology consultant’s report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next? a. Suggest acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program.

Answer 77

c. Obtain history of any recent life stressors. Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite) describes conversion. The nurse must assess the patient fully for emotional conflict and stress before implementing any nursing interventions (acupuncture or exercise program). Although the patient may be malingering, confrontation is nontherapeutic because the patient is using this type of defense mechanism in response to some type of stressor.

Question 78

A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? a. “Let’s call 911 because this freshman student is suicidal.” b. “Give the freshman student this list of university and community resources.” c. “I recommend that you help the freshman student start packing bags to go home.” d. “You must make an appointment for the freshman student to obtain medications.”

Answer 78

b. “Give the freshman student this list of university and community resources.” A nurse can help reduce situational stress factors for individuals. Inform the patient about potential resources. Providing the student with a list of resources is one way to begin this process, as part of secondary prevention strategies. This is not a medical or psychiatric emergency, so calling 911 is not necessary. Not everyone who has sadness needs medications; some need counseling only. Not enough information is given to know whether the student would be best suited to leave college.

Question 79

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use? a. Delegate complex nursing tasks to nursing assistive personnel. b. Strengthen friendships outside the workplace. c. Write for 10 minutes in a journal every day. d. Use progressive muscle relaxation.

Answer 79

b. Strengthen friendships outside the workplace. Strengthening friendships outside of the workplace, arranging for temporary social isolation for personal “recharging” of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating complex nursing tasks to nursing assistive personnel is an inappropriate.

Question 80

A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan? a. Teach the teen about the food pyramid. b. Administer antidiarrheal medications with meals. c. Gently admonish the teen and her parents regarding the consistently poor diet choices. d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

Answer 80

d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends. Tertiary-level interventions assist the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent maturational needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a “typical and normal” teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill and the food pyramid is usually a primary intervention. Administering antidiarrheal medications may help but is not a tertiary-level or maturational intervention. Admonishing the teen and parents is not a tertiary-level intervention, and because this approach is non-therapeutic, it may cause communication problems.

Question 81

A trauma survivor is requesting sleep medication because of “bad dreams.” The nurse is concerned that the patient may be experiencing post-traumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient? a. “Are you reliving your trauma?” b. “Are you having chest pain?” c. “Can you describe your phobias?” d. “Can you tell me when you wake up?”

Answer 81

a. “Are you reliving your trauma?” People who have PTSD often have flashbacks, recurrent and intrusive recollections of the event. The other answers involve assessment of problems not specific to PTSD.

Question 82

A patient in a motor vehicle accident states, “I did not run the red light,” despite very clear evidence on the street surveillance tape. Which defense mechanism is the patient using? a. Denial b. Conversion c. Dissociation d. Compensation

Answer 82

a. Denial Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into nonorganic symptoms. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature.

Question 83

A nurse is teaching the staff about the general adaptation syndrome. In which order will the nurse list the stages, beginning with the first stage? 1. Resistance 2. Exhaustion 3. Alarm a. 3, 1, 2 b. 3, 2, 1 c. 1, 3, 2 d. 1, 2, 3

Answer 83

a. 3, 1, 2 The general adaptation syndrome (GAS), a three-stage reaction to stress, describes how the body responds physiologically to stressors through stages of alarm, resistance, and exhaustion.

Question 84

A young male patient is diagnosed with testicular cancer. Which action will the nurse take first? a. Provide information to the patient. b. Allow time for the patient’s friends. c. Ask about the patient’s priority needs. d. Find support for the family and patient.

Answer 84

c. Ask about the patient’s priority needs. Take time to understand a patient’s meaning of the precipitating event and the ways in which stress is affecting his life. For example, in the case of a woman who has just been told that a breast mass was identified on a routine mammogram, it is important to know what the patient wants (priority needs) and needs most from the nurse. Providing information, allowing time with friends, and finding support may be implemented after finding out what the patient wants or needs.

Question 85

A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing? a. Ego defense model b. Immunity model c. Neuman Systems Model d. Pender’s Health Promotion Model

Answer 85

c. Neuman Systems Model The Neuman Systems Model uses a systems approach, and it helps you understand your patients’ individual responses to stressors and also families’ and communities’ responses. Every person develops a set of responses to stress that constitute the “normal line of defense.” This line of defense helps to maintain health and wellness. Ego defense mechanisms are unconscious coping mechanisms. Immunity is a body’s natural protection mechanism. Pender’s Health Promotion Model focuses on promoting health and managing stress.

Question 86

``` An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0° F Pulse: 102 beats/min Respiratory rate: 26 breaths/min Blood pressure: 140/106 ``` Which hormones should the nurse consider as the most likely causes of the abnormal vital signs? a. ADH and ACTH b. ACTH and epinephrine c. ADH and norepinephrine d. Epinephrine and norepinephrine

Answer 86

d. Epinephrine and norepinephrine During the alarm stage, rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate.

Question 87

A nurse is planning care for a patient that uses displacement. Which information should the nurse consider when planning interventions? a. This copes with stress directly. b. This evaluates an event for its personal meaning. c. This protects against feelings of worthlessness and anxiety. d. This triggers the stress control functions of the medulla oblongata.

Answer 87

c. This protects against feelings of worthlessness and anxiety. Ego-defense mechanisms, like displacement, regulate emotional distress and thus give a person protection from anxiety and stress. Everyone uses them unconsciously to protect against worthlessness and feelings of anxiety. Ego-defense mechanisms help a person cope with stress indirectly and offer psychological protection from a stressful event. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms.

Question 88

Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem? a. Family relocation b. Childhood obesity c. Prolonged poverty d. Loss of stamina

Answer 88

c. Prolonged poverty Environmental and social stressors often lead to developmental problems. Sociocultural refers to societal or cultural factors; poverty is a sociocultural factor. Stamina loss and obesity are health problems, and family relocation is a situational factor.

Question 89

A nurse is helping parents who have a child with attention-deficit/hyperactivity disorder. Which strategy will the nurse share with the parents to reduce stress regarding homework assignments? a. Time-management skills b. Speech articulation skills c. Routine preventative health visits d. Assertiveness training for the family

Answer 89

a. Time-management skills Time-management skills are most related to homework assignment completion. Time-management techniques include developing lists of prioritized tasks. Routine health visits are important but do not directly affect ability to complete homework. Speech and other developmental aspects need to be developed if the child is to be successful, but skill development will not directly reduce homework-related stress. Assertiveness includes skills for helping individuals communicate effectively regarding their needs and desires, but it does not help with homework assignments.

Question 90

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.) a. Cancer b. Diabetes c. Infections d. Allostasis e. Low blood pressure

Answer 90

a. Cancer b. Diabetes c. Infections Stress causes prolonged changes in the immune system, which can result in impaired immune function, and this increases the person’s susceptibility to changes in health, such as increased risk for infection, high blood pressure, diabetes, and cancers. Allostasis is a return to a state of balance; allostatic load occurs with prolonged stress.

Question 91

A 75-year-old woman walks into the emergency department with complaints of “not feeling well.” Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? a. Normal in the older adult b. A need for the patient to be evaluated for cognitive impairment c. A side effect of anti-hypertensive medication d. Pathologic impairment of sensory responses

Answer 91

d. Pathologic impairment of sensory responses This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.

Question 92

The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. “This will help us to identify your baby’s risk for ear infections the first year of life.” b. “Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother.” c. “Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child.” d. “Imitation of sounds is the first step in language development, and it is important to identify alterations early.”

Answer 92

d. “Imitation of sounds is the first step in language development, and it is important to identify alterations early.” Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby’s response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.

Question 93

An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse’s best response? a. “Your wife should increase the spices in your food, as the pneumonia changes your sense of smell.” b. “Notify your doctor immediately, because this is a concerning reaction to the medication.” c. “You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection.” d. “You should see an improvement in the next week or so. Call if this continues.”

Answer 93

d. “You should see an improvement in the next week or so. Call if this continues.” Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

Question 94

An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following? a. “I will make sure that Dad always wears warm socks.” b. “Dad needs to wear his glasses so he can delay the onset of macular degeneration.” c. “I will ask the home health aide to carefully inspect Dad’s feet every day when she helps him bathe.” d. “We will give him only warm foods, so that he doesn’t burn his mouth.”

Answer 94

c. “I will ask the home health aide to carefully inspect Dad’s feet every day when she helps him bathe.” Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one’s own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

Question 95

The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse’s best action to provide recreational activities during the rehabilitation phase? a. Place the television to the left or right of patient’s visual field. b. Encourage the patient to learn braille. c. Suggest use of talking books. d. Provide headphones for listening to music.

Answer 95

c. Suggest use of talking books. Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

Question 96

The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action? a. Notify the physician. b. Document the finding in the records. c. Recheck the reflex after several hours. d. Monitor the eye movements and pupil reactions closely.

Answer 96

a. Notify the physician. The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

Question 97

The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. “I will take my child to the audiologist because he doesn’t seem to hear me except when I look directly at him.” b. “Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.” c. “Making my child wear ear plugs when she goes to a rock concert may save her hearing!” d. “I see now why when my child has a cold, he complains about everything tasting blah!”

Answer 97

b. “Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.” Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

Question 98

During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a. Tympanoplasty b. Irrigation of the ear c. Pure tone test d. Otoscopic exam by a specialist

Answer 98

b. Irrigation of the ear The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

Question 99

A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, “Ow, that was sharp!” How will the nurse interpret the finding when the child said that it was sharp? a. The child’s sensation is intact. b. The child’s reception is intact. c. The child’s perception is intact. d. The child’s reaction is intact.

Answer 99

c. The child’s perception is intact. When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person’s experiences. Sensation is a general term that refers to awareness of sensory stimuli through the body’s sense mechanisms. Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, taste, or sound. Reaction is how a person responds to a perceived stimulus.

Question 100

A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure? 1. Eardrum 2. Perilymph 3. Oval window 4. Bony ossicles 5. Eighth cranial nerve a. 1, 5, 2, 4, 3 b. 1, 3, 4, 2, 5 c. 1, 2, 4, 5, 3 d. 1, 4, 3, 2, 5

Answer 100

d. 1, 4, 3, 2, 5 Vibration of the eardrum transmits through the bony ossicles. Vibrations at the oval window transmit in perilymph within the inner ear to stimulate hair cells that send impulses along the eighth cranial nerve to the brain.

Question 101

A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit? a. The patient frequently cleans out eyes with saline washes. b. The patient applies different spices during mealtime to food. c. The patient turns one ear toward the nurse during conversation. d. The patient isolates self from social situations with groups of people.

Answer 101

c. The patient turns one ear toward the nurse during conversation. Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indicates that the patient alters behavior to accommodate for the sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive.

Question 102

The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Dysequilibrium c. Diabetic retinopathy d. Peripheral neuropathy

Answer 102

a. Xerostomia Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns. Dysequilibrium is balance. Diabetic retinopathy affects vision. Peripheral neuropathy includes numbness and tingling of the affected areas and stumbling gait.

Question 103

A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment? a. Impaired night vision b. Difficulty hearing low pitch c. Heightened sense of smell d. Increased taste discrimination

Answer 103

a. Impaired night vision Night vision becomes impaired as physiological changes in the aging eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.

Question 104

A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse “Should Istop driving?” Which response by the nurse is most therapeutic? a. “Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk.” b. “Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can’t avoid an accident.” c. “No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go.” d. “No, instead you should see your ophthalmologist and get some glasses to help you see better.”

Answer 104

c. “No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go.” Part of the normal aging process is reduced ability to see colors. The nurse should teach the patient new ways to adapt to this deficit. This patient’s accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.

Question 105

A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient’s plan of care? a. Teach the patient about special assistive devices. b. Make the patient talk as much as possible. c. Obtain an order for antidepressant medications. d. Place a consult for a home health nurse.

Answer 105

a. Teach the patient about special assistive devices. Because a stroke often causes partial or complete paralysis of one side of a patient’s body, the patient needs special assistive devices. The nurse should include interventions that help the patient adapt to this deficit while maintaining independence. Teaching the patient to use assistive devices allows the patient to care for him- or herself. Making the patient talk can be inappropriate and demeaning. A home health nurse is not necessary as long as the patient is able to care for him- or herself. Instead of placing the patient on antidepressants, assist the patient in attempting to adapt behavior to the sensory deficit.

Question 106

A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan? a. Risk for falls b. Self-care deficit c. Social isolation d. Impaired physical mobility

Answer 106

c. Social isolation In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Self-care deficit, impaired physical mobility, and fall risk are physiological risks for the patient.

Question 107

During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further? a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance deficit

Answer 107

d. Balance deficit Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. Neurological deficits include peripheral neuropathy and stroke. Visual deficits include presbyopia, cataracts, glaucoma, and macular degeneration. Hearing deficits include presbycusis and cerumen accumulation.

Question 108

A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected? a. Perceptual b. Cognitive c. Affective d. Social

Answer 108

a. Perceptual Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is interacting with the home health nurse, so socialization is not a problem.

Question 109

Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient’s self-care ability? a. “Have you stopped reading books or switched to books on audiotape?” b. “What do you do to protect yourself from injury at work?” c. “Are you able to prepare a meal or write a check?” d. “How does your vision impairment make you feel?”

Answer 109

c. “Are you able to prepare a meal or write a check?” To best understand how vision is affecting self-care ability, the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing, such as preparing meals and writing checks. Switching to books on audiotape gives the nurse an idea of the severity of the deficit but not its impact on activities of daily living. Assessing whether the patient is taking measures for protection is important, but this does not address self-care activities. Emotional assessment of a patient is also important but does not properly address the goal of determining the effect of visual alterations on self-care ability.

Question 110

A nurse is assessing cognitive functioning of a patient. Which action will the nurse take? a. Administer a Mini-Mental State Examination (MMSE). b. Ask the patient to state name, location, and what month it is. c. Ask the patient’s family if the patient is behaving normally. d. Administer the hearing handicap inventory for the elderly (HHIE-S).

Answer 110

a. Administer a Mini-Mental State Examination (MMSE). The MMSE is a formal diagnostic tool that is used to assess a patient’s level of cognitive functioning. The Mini-Mental State Examination (MMSE) is a tool you can use to measure disorientation, change in problem-solving abilities, and altered conceptualization and abstract thinking. Asking the patient orientation questions evaluates only the patient’s orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. The HHIE-S is a 5-minute, 10-item questionnaire that assesses how the individual perceives the social and emotional effects of hearing loss. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment.

Question 111

The nurse is using the Snellen chart. Which patient is the nurse assessing? a. A patient who frequently reports the incorrect time from the clock across the room. b. A patient who is having difficulty remembering how to perform familiar tasks. c. A patient who turns the television up as loud as possible. d. A patient who has trouble saying words.

Answer 111

a. A patient who frequently reports the incorrect time from the clock across the room. The Snellen chart is used to assess vision. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental and cognitive status. Turning the television up louder indicates the need for a hearing assessment. For a patient having trouble saying words a picture board/chart may be used.

Question 112

A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient? a. “Rinse your mouth several times a day to hydrate your taste buds.” b. “Avoid adding spices or lemon juice to food to prevent nausea.” c. “Blend foods together in interesting flavor combinations.” d. “Eat soft foods that are easy to chew and swallow.”

Answer 112

a. “Rinse your mouth several times a day to hydrate your taste buds.” Good oral hygiene keeps the taste buds well hydrated. Having an unpleasant taste in the mouth discourages the patient from eating. Well-seasoned, differently textured food eaten separately heightens taste perception. Avoid blending foods together because this makes it difficult to identify tastes. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable. Flavored vinegar or lemon juice adds tartness to food.

Question 113

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit? a. Body image disturbance b. Social isolation c. Risk for falls d. Fear

Answer 113

c. Risk for falls A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.

Question 114

The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift? a. Expressive b. Receptive c. Global d. Motor

Answer 114

b. Receptive Sensory or receptive aphasia is the inability to understand written or spoken language. A patient is able to express words but is unable to understand questions or comments of others. Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. Global aphasia is the inability to understand language or communicate orally.

Question 115

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking with hands, face, and expressions b. Using a loud voice, enunciating every syllable c. Having direct conversation with the patient in the affected ear d. Repeating the phrase again, if the patient does not understand what the nurse said

Answer 115

a. Speaking with hands, face, and expressions Use visible expressions. Speak with your hands, your face, and your eyes. Do not shout. Speaking in loud tones can distort a patient’s ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient’s unaffected ear.

Question 116

The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning? a. Asks the nurse to test the temperature of the water before entering the bath. b. Places colored stickers on faucet handles to indicate temperature. c. Replaces all lace-up shoes with Velcro straps for ease. d. Uses a heating pad on a low setting to keep warm.

Answer 116

b. Places colored stickers on faucet handles to indicate temperature. If a patient with tactile deficits also has a visual impairment, it is important to be sure that water faucets are clearly marked “hot” and “cold,” or use color codes (i.e., red for hot and blue for cold). Discourage the use of heating pads in this population. Asking the nurse to test the water does not promote independence, although it does promote safety. Velcro is easier for a patient with a tactile deficit to manipulate and promotes self-care but not safety.

Question 117

A nurse is working to prevent blindness. Which preventive action is a priority? a. Screen young adults early for visual impairments. b. Include rubella and syphilis screening in the preconception care plan. c. Instruct parents to report reduced eye contact from their child immediately. d. Administer eye prophylactic antibiotics to newborns within 24 hours after birth.

Answer 117

b. Include rubella and syphilis screening in the preconception care plan. Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases such as rubella, syphilis, chlamydia, and gonorrhea that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible; waiting until children are young adults is too late. Another technique is administering eye prophylaxis in the form of erythromycin ointment approximately 1 hour after an infant’s birth. Reporting reduced eye contact is recommended but is not a preventative measure.

Question 118

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient? a. Administer an opioid medication to help the patient sleep. b. Keep the door open during the night. c. Open the shades at night. d. Provide the patient with earplugs.

Answer 118

d. Provide the patient with earplugs. Control of excessive stimuli becomes an important part of a patient’s care; earplugs provide relief. Quiet time means dimming the lights throughout the unit, closing the shades, and shutting the doors. Allow patients to shut their room door to decrease noise. Opioid medications (for pain relief) should not be the first option; however, antianxiety medications and sleep aids may be considered.

Question 119

The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care? a. Patient will carry a pen and a pad of paper around for communication. b. Patient will recover full use of speech vocabulary in 1 day. c. Patient will thicken drinks to prevent aspiration. d. Patient will communicate nonverbally.

Answer 119

d. Patient will communicate nonverbally. Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. Goals and outcomes need to be realistic and measurable; recovery in 1 day is not realistic. A patient who has expressive aphasia may not be able to speak or write words with a pen and paper. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.

Question 120

The nurse is caring for a group of patients and is monitoring for sensory deprivation. Which patient will the nurse monitor most closely? a. A patient in the ICU under constant monitoring following a myocardial infarction b. A patient on the unit with tuberculosis on airborne precautions c. A patient who recently had a stroke and has left-sided weakness d. A patient receiving hospice care for end-stage lung cancer

Answer 120

b. A patient on the unit with tuberculosis on airborne precautions ``` A group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis. Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation (airborne precautions) is at risk for sensory deprivation because of limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke may have difficulty with tactile sensation but is not at as high a risk for sensory deprivation as is one in isolation. A patient with lung cancer may have deficits, but hospice is present so the patient is at home with others. ```

Question 121

A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take? a. Offer the patient a back rub. b. Hang a “Do not disturb” sign on patient’s door. c. Ask the patient “Would you like a newspaper to read?” d. Place the patient in the room farthest from the nurses’ station.

Answer 121

a. Offer the patient a back rub. Comfort measures such as washing the face and hands and providing back rubs improve the quality of stimulation and lessen the chance of sensory deprivation. The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-nurse interaction and promote further social isolation.

Question 122

The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a “Do not disturb” sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient’s care attempting to enter the room. Which response by the nurse is most appropriate? a. Call for security to remove the surgeon. b. Allow the surgeon to enter. c. Firmly explain that the patient does not wish to have visitors at this time. d. Scold the surgeon for not obeying the sign and respecting the patient’s wishes.

Answer 122

c. Firmly explain that the patient does not wish to have visitors at this time. The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the surgeon to leave regardless of position in the hospital. A creative solution to decrease excessive environmental stimuli that prevents restful, healing sleep is to institute “quiet time” in ICUs. Data collected from one hospital that implemented 1 hour of quiet time daily found decreased staff and unit noise and improved patient satisfaction. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle the situation with professionalism when addressing the surgeon; scolding the visitor is not appropriate.

Question 123

The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion? a. Keep a day-by-day calendar at the patient’s bedside. b. Place a patient observer in the patient’s room for safety. c. Assess the patient’s level of consciousness and document every 4 hours. d. Prepare to discharge once the patient is awake, alert, and oriented.

Answer 123

a. Keep a day-by-day calendar at the patient’s bedside. Keeping a calendar in the patient’s room helps to orient the patient to the dates. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings. Assessing the patient’s level of consciousness is not an action that will directly affect the patient’s confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.

Question 124

A nurse is establishing a relationship with the patient who is severely visually impaired and is teaching the patient how to contact the nurse for assistance. Which action will the nurse take? a. Place a raised Braille sticker on the call button. b. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything. c. Instruct the patient to tell a family member to get the attention of the staff. d. Color code the call light system.

Answer 124

a. Place a raised Braille sticker on the call button. The nurse should devise a plan of care that is accommodating of the patient’s visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Using family members is not the best option. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch at any time. Color coding the call light will not help a severely visually impaired patient.

Question 125

The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority? a. Hearing b. Vision c. Smell d. Taste

Answer 125

a. Hearing Some antibiotics (e.g., streptomycin, gentamicin, and tobramycin) are ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Smell and taste are not as affected.

Question 126

A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for vision, beginning with the first structure? 1. Lens 2. Pupil 3. Retina 4. Cornea 5. Optic nerve a. 2, 1, 4, 5, 3 b. 1, 2, 4, 3, 5 c. 4, 2, 1, 3, 5 d. 5, 2, 4, 1, 3

Answer 126

c. 4, 2, 1, 3, 5 Light rays enter the convex cornea and begin to converge. An adjustment of light rays occurs as they pass through the pupil and lens. Change in the shape of the lens focuses light on the retina. The sensory retina contains the rods and cones (i.e., photoreceptor cells sensitive to stimulation from light). Photoreceptor cells send electrical potentials by way of the optic nerve to the brain.

Question 127

A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Dressing the left side first b. Dressing the right side first c. Dressing the lower extremities first d. Dressing the upper extremities first

Answer 127

a. Dressing the left side first Dressing the left side first will be praised by the nurse. If a patient has partial paralysis and reduced sensation, the patient dresses the affected side first; in this case, the left. A stroke on the right hemisphere affects the left side of the body. The right side or upper and lower extremities are not as effective.

Question 128

A home care nurse is inspecting a patient’s house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.) a. Stairway faintly lit b. Bathtub with grab bars c. Scatter rugs in the kitchen d. Absence of smoke alarms e. Low-pile carpeting in the living room f. Level thresholds between bathroom and bedroom

Answer 128

a. Stairway faintly lit c. Scatter rugs in the kitchen d. Absence of smoke alarms Assess the patient’s home for common hazards, including the following: (1) loose area rugs and runner placed over carpeting, (2) poor lighting in stairways, and (3) absence of smoke alarms. Because of reduced depth perception, patients can trip on throw rugs, runners, or the edge of stairs. A bathtub with grab bars is safe and does not need to be addressed. Teach patients and family members to keep all flooring in good repair, and advise them to use low-pile carpeting. Thresholds between rooms need to be level with the floor.

Question 129

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-Pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil’s reaction to light.

Answer 129

a. A Tono-Pen will be applied to the surface of the eye. 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.

Question 130

The nurse is performing an eye examination on a 76-yr-old patient. The nurse should refer the patient for a more extensive assessment based on which finding? a. The patient’s sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

Answer 130

b. The patient reports persistent photophobia. Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences in assessment and would not be unusual in a 76-yr-old patient.

Question 131

The nurse performing an eye examination will document normal findings for accommodation when a. shining a light into the patient’s eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient’s pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved toward the patient’s eyes.

Answer 131

d. the pupils constrict while fixating on an object being moved toward the patient’s eyes. Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object that is being moved from far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

Question 132

Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes

Answer 132

c. Blurred vision and light sensitivity Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts. Loss of peripheral vision is a sign of glaucoma.

Question 133

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 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? a. OS 20/50; OD 20/40 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

Answer 133

a. OS 20/50; OD 20/40 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.

Question 134

When assessing a patient’s consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both pupils. c. shine a light into one eye and observe responses of both pupils. d. instruct the patient to follow a moving object using only the eyes.

Answer 134

c. shine a light into one eye and observe responses of both pupils. The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye and then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

Question 135

The nurse is observing a student who is preparing to perform an ear examination for a 30-yr-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient’s head. d. stops inserting the otoscope after observing impacted cerumen.

Answer 135

b. chooses a speculum larger than the ear canal. The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

Question 136

When obtaining a health history from a 49-yr-old patient, which patient statement is most important to communicate to the primary health care provider? a. “My eyes are dry now.” b. “It is hard for me to see at night.” c. “My vision is blurry when I read.” d. “I can’t see as far over to the side.”

Answer 136

d. “I can’t see as far over to the side.” 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.

Question 137

A 65-yr-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient’s treatment plan? a. “I take metoprolol (Lopressor) for angina.” b. “I take aspirin when I have a sinus headache.” c. “I have had frequent episodes of conjunctivitis.” d. “I have not had an eye examination for 10 years.”

Answer 137

a. “I take metoprolol (Lopressor) for angina.” It is important to note whether the patient takes any -adrenergic blockers because this classification of medications is also 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

Question 138

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse’s instructions for this test include asking the patient to a. stand 20 feet away from the wall chart. b. follow the examiner’s finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes.

Answer 138

a. stand 20 feet away from the wall chart. When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner’s fingers with the eyes tests extraocular movements.

Question 139

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision c. Ineffective health maintenance related to inability to see surroundings d. Ineffective coping related to inability to admit the impact of the eye injury

Answer 139

b. Risk for falls related to temporary decrease in stereoscopic vision 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 health maintenance, disturbed body image, or ineffective denial.

Question 140

Which information will the nurse provide to the patient scheduled for refractometry? a. “You should not take any of your eye medicines before the examination.” b. “You will need to wear sunglasses for a few hours after the examination.” c. “The doctor will shine a bright light into your eye during the examination.” d. “The surface of your eye will be numb while the doctor does the examination.”

Answer 140

b. “You will need to wear sunglasses for a few hours after the examination.” The pupils are dilated 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.

Question 141

The nurse is assessing a 65-yr-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. “Hold this card and read the print out loud.” b. “Cover one eye while reading the wall chart.” c. “You’ll feel a short burst of air directed at your eyeball.” d. “A light will be used to look for a change in your pupils.”

Answer 141

a. “Hold this card and read the print out loud.” The Jaeger card is used to assess near vision problems and presbyopia in persons older than 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

Question 142

A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear.

Answer 142

b. report any burning or pain at the IV site. Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

Question 143

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.

Answer 143

b. rotary chair testing. 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.

Question 144

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, “I have to sleep with the television on.” Which follow-up question is 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 ringing in your ears?” d. “Are you ever dizzy when you are lying down?”

Answer 144

c. “Have you noticed ringing in your ears?” 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 “Are you ever dizzy when you are lying down?” would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint pain. The response “What time do you usually fall asleep?” would not be helpful in assessing problems with the patient’s ears.

Question 145

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient.

Answer 145

b. Place a fall-risk bracelet on the patient. Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing.

Question 146

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol taken to prevent angina b. Acetaminophen taken frequently for headaches c. Ibuprofen taken for 20 years to treat osteoarthritis d. Albuterol taken since early childhood to treat asthma

Answer 146

c. Ibuprofen taken for 20 years to treat osteoarthritis Non-steroidal anti-inflammatory drugs are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

Question 147

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. facing the patient directly when speaking. b. speaking slowly and distinctly to the patient. c. administering both the Rinne and Weber tests. d. encouraging the patient to ambulate independently.

Answer 147

d. encouraging the patient to ambulate independently. Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

Question 148

The nurse in the eye clinic is examining a 67-yr-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. Warn the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

Answer 148

d. Use an ophthalmoscope to examine the posterior eye chambers. 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-yr-old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

Question 149

The nurse should report which assessment finding immediately to the health care provider? a. Cone of light is visible. b. Tympanum is blue-tinged. c. Skin in the ear canal is dry and scaly. d. Cerumen is present in the auditory canal.

Answer 149

b. Tympanum is blue-tinged. 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.

Question 150

Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

Answer 150

b. Tuning fork Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.

Question 151

Which action should the nurse take when providing patient teaching to a 76-yr-old patient with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching. d. Wait until family members have left before initiating teaching.

Answer 151

c. Ask for permission to turn off the television before teaching. Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching.

Question 152

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient’s external ear for redness, swelling, or presence of skin lesions.

Answer 152

b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN.

Question 153

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-yr-old who has noticed increasing loss of peripheral vision b. 74-yr-old who has difficulty seeing well enough to drive at night c. 60-yr-old who has difficulty hearing clearly in a noisy environment d. 64-yr-old who has decreased hearing and ear “stuffiness” without pain

Answer 153

a. 71-yr-old who has noticed increasing loss of peripheral vision Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision.

Question 154

The nurse evaluates that wearing bifocals improved the patient’s myopia and presbyopia by assessing for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.

Answer 154

b. both near and distant vision. The lenses are prescribed to correct the patient’s near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient’s bifocals are effective.

Question 155

A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to a. irrigate the eyes with saline solution. b. schedule an appointment for eye surgery. c. use a gentle baby shampoo to clean the eyelids. d. apply cool compresses to the eyes three times daily.

Answer 155

c. use a gentle baby shampoo to clean the eyelids. Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

Question 156

The safest technique for the nurse to use when assisting a blind patient in ambulating to the bathroom is to a. have the patient place a hand on the nurse’s shoulder and guide the patient. b. lead the patient slowly to the bathroom, holding on to the patient by the arm. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient, allowing the patient to hold the nurse’s elbow.

Answer 156

d. walk slightly ahead of the patient, allowing the patient to hold the nurse’s elbow. 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.

Question 157

A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection? a. Apply cold compresses. b. Discard used eye cosmetics. c. Wash the scalp and eyebrows with an antiseborrheic shampoo. d. Be examined for recurrent sexually transmitted infections (STIs).

Answer 157

b. Discard used eye cosmetics. Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STI testing

Question 158

The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? a. Wash hands frequently and avoid touching the eyes. b. Apply antibiotic drops to the eye several times daily. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

Answer 158

a. Wash hands frequently and avoid touching the eyes. The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus, and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications.

Question 159

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain hand-held magnifiers

Answer 159

d. Where to obtain hand-held magnifiers Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living. Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.

Question 160

The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? a. Applying topical corticosteroids to decrease inflammation b. Discussing the need for sexually transmitted infection testing c. Educating about the use of antiviral eyedrops to treat the infection d. Assisting with applying for community visual rehabilitation services

Answer 160

b. Discussing the need for sexually transmitted infection testing Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate.

Question 161

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

Answer 161

b. Administration of corticosteroid drops Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. 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 because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

Question 162

In reviewing a 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.

Answer 162

d. peripheral vision. 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.

Question 163

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The use of eye patches to reduce movement of the operative eye b. The need to wear dark glasses to protect the eyes from bright light c. The purpose of maintaining the head resting in a prescribed position d. The procedure for dressing changes when the eye dressing is saturated

Answer 163

c. The purpose of maintaining the head resting in a prescribed position Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. Dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure.

Question 164

A 72-yr-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. “I will use drops to keep my pupils dilated until my appointment.” b. “I will need to use brighter lights to read for at least the next week.” c. “I will not use facial lotions near my eyes during the recovery period.” d. “I will cover up with long-sleeved shirts and pants for the next 5 days.”

Answer 164

d. “I will cover up with long-sleeved shirts and pants for the next 5 days.” The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

Question 165

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient’s visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient’s depth perception when climbing stairs.

Answer 165

b. noting any changes in the patient’s visual field. POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

Question 166

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient’s statement is a. “Those symptoms may indicate a need for a change in dosage of the eye drops.” b. “The drops are uncomfortable, but it is important to use them to retain your vision.” c. “These are normal side effects of the drug, which should be less noticeable with time." d. “Notify your health care provider so that different eye drops can be prescribed for you.”

Answer 166

b. “The drops are uncomfortable, but it is important to use them to retain your vision.” 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 and do not indicate a need for a dosage or medication change.

Question 167

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medication should the nurse question? a. Morphine sulfate 4 mg IV b. Diazepam (Valium) 5 mg IV c. Betaxolol (Betoptic) 0.25% eyedrops d. Scopolamine patch (Transderm Scop) 1.5 mg

Answer 167

d. Scopolamine patch (Transderm Scop) 1.5 mg Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient.

Question 168

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 at this time? a. Grieving related to current loss of functional vision b. Ineffective health management related to inability to see c. Anxiety related to the possibility of permanent vision loss d. Situational low self-esteem related to loss of visual function

Answer 168

c. Anxiety related to the possibility of permanent vision loss 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. There is no indication of impaired self-esteem at this time.

Question 169

To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic? a. Perform tympanometry. b. Schedule otoscopic examinations. c. Administer influenza immunizations. d. Discuss exposure to amplified music.

Answer 169

d. Discuss exposure to amplified music. 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. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients.

Question 170

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. “I will apply the eardrops to the cotton wick in the ear canal.” b. “I can use aspirin or acetaminophen (Tylenol) for pain relief.” c. “I will clean the ear canal daily with a cotton-tipped applicator.” d. “I can use warm compresses to the outside of the ear for comfort.”

Answer 170

c. “I will clean the ear canal daily with a cotton-tipped applicator.” 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.

Question 171

The nurse will instruct a patient who has undergone a left tympanoplasty to a. remain on bed rest. b. keep the head elevated. c. avoid blowing the nose. d. irrigate the left ear canal.

Answer 171

c. avoid blowing the nose. 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.

Question 172

The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of “popping” in the ear. c. Clear fluid is visible through the tympanic membrane. d. The patient frequently asks the nurse to repeat information.

Answer 172

a. The patient has a temperature of 100.6° F. 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, decreased hearing, and fluid in the middle ear are indications 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.

Question 173

A patient with Ménière’s disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient’s room. b. Encourage increased oral fluid intake. c. Change the patient’s position every 2 hours. d. Keep the head of the bed elevated 45 degrees.

Answer 173

a. Dim the lights in the patient’s room. A darkened, quiet room will decrease the symptoms of the acute attack of Ménière’s disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort.

Question 174

Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. “I will leave the ear wick in place while administering the drops.” b. “I will hold the tip of the dropper above the ear to administer the drops.” c. “I will refrigerate the medication until I am ready to administer the drops.” d. “I should lie down before and for 5 minutes after administering the drops.”

Answer 174

c. “I will refrigerate the medication until I am ready to administer the drops.” Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate.

Question 175

An older patient who is being admitted to the hospital repeatedly asks the nurse to “speak up so that I can hear you.” Which action should the nurse take? a. Increase the speaking volume. b. Overenunciate while speaking. c. Speak normally but more slowly. d. Use more facial expressions when talking.

Answer 175

c. Speak normally but more slowly. 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.

Question 176

A 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. Keep the volume low on the hearing aids for the first week. b. Experiment with volume and hearing in a quiet environment. c. Add the second hearing aid after making adjustments to the first hearing aid. d. Begin wearing the hearing aids for an hour a day, gradually increasing the use.

Answer 176

b. Experiment with volume and hearing in a quiet environment. Initially the patient should use the hearing aids in a quiet environment such as 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.

Question 177

Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants are not useful for patients with congenital deafness. b. Cochlear implants are most helpful as an early intervention for presbycusis. c. Cochlear implants improve hearing in patients with conductive hearing loss. d. Cochlear implants require extensive training in order to reach the full benefit.

Answer 177

d. Cochlear implants require extensive training in order to reach the full benefit. Extensive rehabilitation is required after cochlear implants 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.

Question 178

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. “I will wash my hands often during the day.” b. “I will remove my contact lenses at bedtime.” c. “I will not share towels with my friends or family.” d. “I will monitor my family for eye redness or drainage.”

Answer 178

b. “I will remove my contact lenses at bedtime.” Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact.

Question 179

Which information will the nurse include when teaching a patient with herpes simplex type 1 keratitis? a. Use of natamycin (Natacyn) antifungal eyedrops b. Application of corticosteroid ophthalmic ointment c. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d. Completion of the prescribed series of oral acyclovir (Zovirax)

Answer 179

d. Completion of the prescribed series of oral acyclovir (Zovirax) Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex type 1 is viral, not parasitic or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis.

Question 180

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is important to report to the health care provider at this time? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes 2 antihypertensive medications. d. The patient gets nauseated with general anesthesia.

Answer 180

c. The patient takes 2 antihypertensive medications. 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. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia.

Question 181

During the preoperative assessment of a patient scheduled for a right cataract extraction and intraocular lens implantation, it is important for the nurse to assess a. the visual acuity of the patient’s left eye. b. how long the patient has had the cataract. c. for presence of a white pupil in the right eye. d. for a history of reactions to general anesthetics.

Answer 181

a. the visual acuity of the patient’s left eye. 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. 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 affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics.

Question 182

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to a. obtain more information about the cause of the patient’s vision loss. b. obtain information from the spouse about the patient’s special needs. c. make eye contact with the patient and ask about any need for assistance. d. perform an evaluation of the patient’s visual acuity using a Snellen chart.

Answer 182

c.make eye contact with the patient and ask about any need for assistance. Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient’s facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient’s visual acuity are not priorities during the initial assessment.

Question 183

Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Evaluate a patient’s ability to administer eye drops. b. Check a patient’s visual acuity using a Snellen chart. c. Inspect a patient’s external ear for signs of irritation caused by a hearing aid. d. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D.

Answer 183

b. Check a patient’s visual acuity using a Snellen chart. Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice.

Question 184

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee’s eyes. Which action will the nurse take? a. Apply cool compresses. b. Flush the eyes with saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

Answer 184

b. Flush the eyes with saline. In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available. No other interventions should delay flushing the eyes.

Question 185

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière’s disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene? a. UAP raise the side rails on the bed. b. UAP turn on the patient’s television. c. UAP place an emesis basin at the bedside. d. UAP helps the patient turn to the right side.

Answer 185

b. UAP turn on the patient’s television. Watching television may exacerbate the symptoms of an acute attack of Ménière’s disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack.

Question 186

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient requests a prescription refill for next week. b. The patient feels uncomfortable wearing an eye patch. c. The patient complains that the vision has not improved. d. The patient reports eye pain rated 5 (on a 0 to 10 scale).

Answer 186

d. The patient reports eye pain rated 5 (on a 0 to 10 scale). Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring.

Question 187

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of “a curtain” over part of the visual field.

Answer 187

d. The patient complains of “a curtain” over part of the visual field. The patient’s sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient’s history of being hit in the eye.

Question 188

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient’s head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

Answer 188

b. The nurse encourages the patient to cough. Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

Question 189

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient’s hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

Answer 189

b. Application of a warm compress to a patient’s hordeolum Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

Question 190

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Assess cranial nerve functions. b. Administer the prescribed analgesic. c. Check the patient’s oxygen saturation. d. Examine the eye for evidence of trauma.

Answer 190

c. Check the patient’s oxygen saturation. The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.

Question 191

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

Answer 191

b. Mannitol (Osmitrol) 100 mg IV 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 are also appropriate for a patient with glaucoma but would not be the first medication administered.

Question 192

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere’s disease is a. risk for falls related to episodic 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.

Answer 192

a. risk for falls related to episodic dizziness. 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.

Question 193

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a. Oral temperature is 100.8° F (38.1° C). b. The patient complains of ear “fullness.” c. Small amount of dried drainage on dressing. d. The patient reports that hearing has gotten worse.

Answer 193

a. Oral temperature is 100.8° F (38.1° C). An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery.

Question 194

A 75-yr-old patient who lives alone at home tells the nurse, “I am afraid of losing my independence because my eyes don’t work as well they used to.” Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Ask the patient about what type of vision problems are being experienced. c. Explain that there are many ways to compensate for decreases in visual acuity. d. Suggest ways of improving the patient’s safety, such as using brighter lighting.

Answer 194

b. Ask the patient about what type of vision problems are being experienced. The nurse’s initial action should be further assessment of the patient’s concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment.

Question 195

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of “floaters” in the patient’s visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

Answer 195

c. Remind the patient it may take months to restore vision after transplant. Vision may not be restored for up to 1 year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because “floaters” are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery.

Question 196

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

Answer 196

b. Fill the irrigation syringe with body-temperature solution. Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe.

Question 197

Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? a. Teach the patient about use of medications to reduce symptoms. b. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks. c. Teach the patient that canalith repositioning may be used to reduce dizziness. d. Speak with a low-pitched voice so that the patient is able to hear instructions.

Answer 197

c. Teach the patient that canalith repositioning may be used to reduce dizziness. The Epley maneuver is used to reposition “ear rocks” in BPPV. Medications and placement in a dark room may be used to treat Ménière’s disease, but are not necessary for BPPV. There is no hearing loss with BPPV.

Question 198

When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a. applying sunscreen. b. preventing fall injuries. c. decreasing dietary sodium. d. chemotherapy side effects.

Answer 198

b. preventing fall injuries. Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy.

Question 199

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with purulent left eye discharge and conjunctival inflammation b. Patient with acute right eye pain that began while using home power tools c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière’s disease and is complaining of nausea, vomiting, and dizziness

Answer 199

b. Patient with acute right eye pain that began while using home power tools The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss.

Question 200

The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-yr-old patient as shown in the accompanying figure, which action should the nurse take first? History: Type 2 diabetes for 5 years; Mild hearing loss; Sudden loss of left eye peripheral vision today Physical Assessment: PERRLA; EOMs intact; Cerumen obstructive view of tympanic membranes Vital Signs: Pulse 102; BP 146/90; Resp 24; Temp 97.9. a. Check the patient’s blood glucose level. b. Take the blood pressure on the left arm. c. Use an irrigating syringe to clean the ear canals. d. Report a vision change to the health care provider.

Answer 200

d. Report a vision change to the health care provider. The sudden change in peripheral vision may indicate an acute problem, such as retinal detachment, that should be treated quickly to preserve vision. The other data about the patient are not indicative of any acute problem. The other actions are also appropriate, but the highest priority for this patient is prevention of blindness.

Question 201

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders

Answer 201

b. Screening for malignancies Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

Question 202

Which example should the nurse use to explain an infant’s “passive immunity” to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

Answer 202

b. Breastfeeding Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy.

Question 203

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils

Answer 203

a. IgE Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

Question 204

An older adult patient who is having an annual check-up tells the nurse, “I feel fine, and I don’t want to pay for all these unnecessary cancer screening tests!” Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals

Answer 204

a. Consequences of aging on cell-mediated immunity The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

Question 205

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. “I need to find a different way to earn extra money.” b. “I will take oral antihistamines before going to work.” c. “I will get a prescription for epinephrine and learn to self-inject it.” d. “I should wear a Medic-Alert bracelet indicating my allergy to bee stings.”

Answer 205

b. “I will take oral antihistamines before going to work.” Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient’s hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

Question 206

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. “Do not eat anything for about 6 hours before the testing.” b. “Take an oral antihistamine about an hour before the testing.” c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.” d. “Reaction to the testing will take about 48 to 72 hours to occur.”

Answer 206

c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.” Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

Question 207

The nurse reviewing a clinic patient’s medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient’s sensitivity to the allergen with a repeat skin test.

Answer 207

c. Consult with the health care provider about giving a lower allergen dose. Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

Question 208

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient’s history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

Answer 208

b. Document the patient’s history and teach about clinical manifestations of a type I latex allergy. The patient’s allergy history and occupation indicate a risk of developing a latex allergy. The patient should be taught about symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the exposure to latex from latex gloves.

Question 209

A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma

Answer 209

b. Gamma globulin The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

Question 210

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. “I need to be monitored closely for development of malignant tumors.” b. “After a couple of years I will be able to stop taking the cyclosporine.” c. “If I develop acute rejection episode, I will need additional types of drugs.” d. “The drugs are combined to inhibit different ways the kidney can be rejected.”

Answer 210

b. “After a couple of years I will be able to stop taking the cyclosporine.” Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

Question 211

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient’s health history has implications for planning patient teaching about the medication at this time? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day.

Answer 211

c. The patient drinks grapefruit juice every day. Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function.

Question 212

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list

Answer 212

b. Administration of immunosuppressant medications Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing.

Question 213

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

Answer 213

c. A patient who is recovering from an anaphylactic reaction to a bee sting There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns.

Question 214

A patient in the health care provider’s office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a. Monitor the patient’s edema. b. Administer a dose of epinephrine. c. Provide a prescription for oral antihistamines d. Ask the patient about the use of new skin products.

Answer 214

b. Administer a dose of epinephrine. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of additional edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction.

Question 215

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse’s priority action? a. Provide high-flow oxygen. b. Administer antihistamines. c. Assess the patient’s airway. d. Remove the stinger from the site.

Answer 215

c. Assess the patient’s airway. The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient’s symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance.

Question 216

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient’s other allergen tests.

Answer 216

b. Place a tourniquet above the site. Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may occur, but the tourniquet application slows the allergen progress into the patient’s system, allowing treatment of the anaphylactic response. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of anaphylaxis.

Question 217

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer a skin test by the cutaneous scratch method.

Answer 217

d. Administer a skin test by the cutaneous scratch method. LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching.

Question 218

The health care provider asks the nurse whether a patient’s angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Obtain the patient’s blood pressure and heart rate. b. Question the patient about any clear nasal discharge. c. Observe for swelling of the patient’s lips and tongue. d. Assess the patient’s extremities for wheal and flare lesions.

Answer 218

c. Observe for swelling of the patient’s lips and tongue. Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

Question 219

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient–donor crossmatching are positive d. Panel of reactive antibodies (PRA) percentage is low

Answer 219

c. Results of patient–donor crossmatching are positive Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable.

Question 220

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient’s IgG level is increased. b. The injection site is red and swollen. c. The patient’s symptoms did not improve in 2 months. d. There is a 2-cm wheal at the site of the allergen injection.

Answer 220

d. There is a 2-cm wheal at the site of the allergen injection. A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient’s symptoms is not expected after a few months.

Question 221

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask.

Answer 221

A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last.

Question 222

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders

Answer 222

b. Screening for malignancies Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

Question 223

Which example should the nurse use to explain an infant’s “passive immunity” to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

Answer 223

b. Breastfeeding Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy.

Question 224

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils

Answer 224

a. IgE Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

Question 225

An older adult patient who is having an annual check-up tells the nurse, “I feel fine, and I don’t want to pay for all these unnecessary cancer screening tests!” Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals

Answer 225

a. Consequences of aging on cell-mediated immunity The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

Question 226

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. “I need to find a different way to earn extra money.” b. “I will take oral antihistamines before going to work.” c. “I will get a prescription for epinephrine and learn to self-inject it.” d. “I should wear a Medic-Alert bracelet indicating my allergy to bee stings.”

Answer 226

b. “I will take oral antihistamines before going to work.” Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient’s hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

Question 227

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. “Do not eat anything for about 6 hours before the testing.” b. “Take an oral antihistamine about an hour before the testing.” c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.” d. “Reaction to the testing will take about 48 to 72 hours to occur.”

Answer 227

c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.” Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

Question 228

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

Answer 228

b. Gown c. Gloves Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

Question 229

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

Answer 229

a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. e. Hand washing is effective in preventing many viral and bacterial infections. All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.

Question 230

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden’s nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

Answer 230

b. Discomfort with joint movement Initial symptoms of OA include pain with joint movement. Heberden’s nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

Question 231

Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication? a. The patient has gained 3 lb. b. The patient has dark-colored stools. c. The patient’s pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).

Answer 231

b. The patient has dark-colored stools. Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient’s ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

Question 232

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. “I can exercise every day to help maintain joint motion.” b. “I will take 1 g of acetaminophen (Tylenol) every 4 hours.” c. “I will take a shower in the morning to help relieve stiffness.” d. “I can use a cane to decrease the pressure and pain in my hip.”

Answer 232

b. “I will take 1 g of acetaminophen (Tylenol) every 4 hours.” No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

Question 233

The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? a. Prednisone b. Adalimumab (Humira) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

Answer 233

c. Capsaicin cream (Zostrix) Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis.

Question 234

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

Answer 234

c. Assess the nodules for skin breakdown or infection. Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

Question 235

Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

Answer 235

b. Encourage the patient to take a nap in the afternoon. Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve flexibility and strength of affected joints, as well as the patient’s general endurance.

Question 236

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is appropriate? a. Ask the HCP about discontinuing methotrexate b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears. d. Teach the patient about adverse effects of the RA medications.

Answer 236

c. Suggest the patient use over-the-counter (OTC) artificial tears. The patient’s dry eyes are consistent with Sjögren’s syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself.

Question 237

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

Answer 237

b. Applying cold packs before exercise may decrease joint pain. Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

Question 238

Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose b. C-reactive protein c. Serum electrolytes d. Liver function tests

Answer 238

b. C-reactive protein C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

Question 239

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.

Answer 239

a. avoid activities requiring repetitive use of the same muscles and joints. Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

Question 240

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a brief routine of isometric exercises. b. a warm bath followed by a short rest. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

Answer 240

b. a warm bath followed by a short rest. Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

Question 241

Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. avoiding concurrent aspirin use. b. symptoms of gastrointestinal (GI) bleeding. c. self-administration of subcutaneous injections. d. taking the medication with at least 8 oz of fluid.

Answer 241

c. self-administration of subcutaneous injections. Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued.

Question 242

A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? a. “You need to see a family therapist for some help with stress.” b. “Tell me more about the situations that are causing you stress.” c. “Your family should understand the impact of your rheumatoid arthritis.” d. “Perhaps it would be helpful for your family to be involved in a support group.”

Answer 242

b. “Tell me more about the situations that are causing you stress.” The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

Question 243

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about management of the condition? a. Exercise by taking long walks. b. Do daily deep-breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

Answer 243

b. Do daily deep-breathing exercises. Deep-breathing exercises are used to decrease the risk for pulmonary complications that may result from reduced chest expansion that can occur with AS. Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

Question 244

A patient hospitalized with a fever and red, hot, painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. had several knee injuries as a teenager. b. recently returned from South America. c. is sexually active with multiple partners. d. has a parent who has rheumatoid arthritis.

Answer 244

c. is sexually active with multiple partners. Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

Question 245

The nurse notices a circular lesion with a red border and clear center on the arm of a summer camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

Answer 245

c. Ask the patient about recent outdoor activities. The patient’s clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient’s symptoms do not suggest cardiac or abdominal problems or lack of immunization.

Question 246

A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. methotrexate b. anakinra (Kineret). c. etanercept (Enbrel). d. doxycycline (Vibramycin).

Answer 246

d. doxycycline (Vibramycin). Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

Question 247

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. reduced joint pain. b. increased urine output. c. elevated serum uric acid. d. increased white blood cells (WBC).

Answer 247

a. reduced joint pain. Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase.

Question 248

A patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. hydrochlorothiazide. d. oxycodone (Roxicodone).

Answer 248

a. sertraline (Zoloft). Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

Question 249

The nurse is planning care for a patient with hypertension and gout who has a red, painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach the patient to avoid use of acetaminophen (Tylenol).

Answer 249

c. Use a footboard to hold bedding away from the toe. Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management.

Question 250

A patient has scleroderma manifested by CREST (calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep the environment warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

Answer 250

b. Keep the environment warm and draft free. Keeping the room warm will decrease the incidence of Raynaud’s phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose or to assist the patient to the bathroom every 2 hours.

Question 251

The nurse determines additional instruction is needed when a patient diagnosed with scleroderma makes which statement? a. “Paraffin baths can be used to help my hands.” b. “I should lie down for an hour after each meal.” c. “Lotions will help if I rub them in for a long time.” d. “I should perform range-of-motion exercises daily.”

Answer 251

b. “I should lie down for an hour after each meal.” Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate teaching has been effective.

Question 252

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, “My arthritis isn’t that bad yet. The side effects of methotrexate are worse than the arthritis.” The most appropriate response by the nurse is a. “You have the right to refuse to take the methotrexate.” b. “Methotrexate is less expensive than some of the newer drugs.” c. “It is important to start methotrexate early to decrease the extent of joint damage.” d. “Methotrexate is effective and has fewer side effects than some of the other drugs.”

Answer 252

c. “It is important to start methotrexate early to decrease the extent of joint damage.” Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

Question 253

Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? a. The patient has joint pain and stiffness. b. The patient’s blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient’s erythrocyte sedimentation rate (ESR) has increased.

Answer 253

b. The patient’s blood glucose is 165 mg/dL. Corticosteroids have the potential to cause diabetes mellitus. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.

Question 254

The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

Answer 254

d. The patient sleeps with two pillows under the head The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective.

Question 255

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient’s home routine indicates a need for teaching regarding gout management? a. The patient sleeps 8-10 hours each night. b. The patient usually eats beef once a week. c. The patient takes one aspirin a day to prevent angina. d. The patient usually drinks about 3 quarts water each day.

Answer 255

c. The patient takes one aspirin a day to prevent angina. Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient’s sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

Question 256

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision b. Joint tenderness c. Abdominal cramping d. Elevated blood pressure

Answer 256

a. Blurred vision Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported.

Question 257

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient’s health history is important for the nurse to report to the health care provider related to the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

Answer 257

b. The patient is trying to get pregnant before her disease becomes more severe. Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

Question 258

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/μL. d. The erythrocyte sedimentation rate is elevated.

Answer 258

c. The white blood cell (WBC) count is 1500/μL. Bone marrow suppression is a possible side effect of methotrexate, and the patient’s low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

Question 259

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 86/50 mm Hg. b. The patient says the knee pain is severe. c. The white blood cell count is 11,500/μL. d. The patient is taking ibuprofen (Motrin).

Answer 259

a. The blood pressure is 86/50 mm Hg. The low blood pressure suggests the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

Question 260

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job b. A 38-yr-old man who plays on a summer softball team c. A 56-yr-old woman who works on an automotive assembly line d. A 38-yr-old woman who is newly diagnosed with diabetes mellitus

Answer 260

c. A 56-yr-old woman who works on an automotive assembly line OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.

Question 261

Which action will the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis? a. Advise the patient to sleep on the back with a flat pillow. b. Emphasize that application of heat may worsen symptoms. c. Schedule annual laboratory assessment for the HLA-B27 antigen. d. Assist patient to choose physical activities that involve spinal flexion.

Answer 261

a. Advise the patient to sleep on the back with a flat pillow. Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (e.g., sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen is assessed for initial diagnosis but is not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain.

Question 262

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden’s nodes. c. Patient’s knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

Answer 262

d. Laboratory results indicate blood urea nitrogen (BUN) is elevated. Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient’s diagnosis of osteoarthritis and will not require an immediate change in the patient’s treatment plan.

Question 263

A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? a. Red, scaly patches are noted on the arms. b. Crackles are auscultated in the lung bases. c. Hemoglobin is 11.1g/dL, and hematocrit is 35%. d. Patient has continued pain after first week of etanercept therapy.

Answer 263

b. Crackles are auscultated in the lung bases. Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.

Question 264

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? a. Monitor for difficulty in breathing. b. Document the patient’s oral intake. c. Check finger strength and movement. d. Apply capsaicin (Zostrix) cream to hands.

Answer 264

b. Document the patient’s oral intake. Monitoring and documenting patient’s oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice, and should be done by RNs.

Question 265

When reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient?

Answer 265

(You'll have to look up a picture of what this actually looks like). Swan neck deformity involves distal interphalangeal joint hyperflexion and proximal interphalangeal joint hyperextension of the hands. The other deformities are also associated with rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus.