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Med-Surg Final Exam Review Questions With
Complete Solutions
A client dx with a cataract comes into the clinic. What assessments should the nurse observe in this client? blurred or cloudy visual image a colleague has been splashed in the eye with cleaning solution. Which of the following would be the priority? irrigating the eye immediately with tap water the nurse is teaching the client to instill eye drops. Which statement is correct? "wash your hands before and after instilling eye drops and do not touch the tip of the bottle" A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking a herbal remedy for her condition that was recommended by a work colleague. what instructions should the nurse provide to the client? the client should discuss this new remedy with her ophthalmologist A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home?
Avoid bending the head below the waist A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurse observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate? signs and symptoms of conjunctivitis which type of glaucoma presents an ocular emergency? Acute angle-closure glaucoma A client who presents for an eye examination is dx as having a visual acuity of 20/40. The client asks the nurse what these numbers specifically mean. What is a correct response by the nurse? A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away A client has informed the home health nurse that she recently noticed distortions when she looks at the Amsler grid that she has mounted on her fridge. What is the nurse's most appropriate action? Arrange for the client to be assessed for muscular degeneration A 56-year-old client has come to the clinic for his routine eye examination and is told he needs bifocals. The client asks the
A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client? generously flush the affected eye with normal saline or water A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what? a new floater in vision the nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a hx of glaucoma. the nurse should anticipate the use of what medications cholinergics a nurse is teaching a client with glaucoma how to administer eye drops to achieve max absorption. The nurse should teach the client to perform what action? instill the medication in the conjunctival sac the nurse should recognize the greatest risk for the development of blindness in which of the following clients A 58-year-old woman with macular degeneration A 6-year-old is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with
viral conjunctivitis. What is the most important information to discuss with the parents and child? Hand washing can prevent the spread of the disease to others Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? Isolate affected residents from residents who have not developed conjunctivitis. A patient presents to an eye clinic with a number of symptoms related to his diminished vision. An initial history leads the nurse practitioner to suspect that the patient has acute angle- closure glaucoma. Which of the following symptoms would apply to this diagnosis? Select all that apply. -severe eye pain -reddening of the eye -sudden onset of visual disturbance -nausea/vomiting An elderly client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which of the following symptoms to be exhibited in this client? Select all that apply. -flashing lights -cobwebs in vision field
A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate with the client? Sit or stand in front of the client when speaking A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse? Write down the steps of the procedure for the patient to read before beginning the treatment The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care? Limit foods that are high in sodium. The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client? To reduce the production of fluid in the inner ear You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis.
Knowing the complications of the disorder, what should you keep always ready at the bedside? Intubation tray and suction apparatus The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? Take small meals of soft consistency The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? Monitoring neurologic status closely The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? Respiratory Bell palsy is a disorder of which cranial nerve? Facial (VII) A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client?
-increasing disability -becoming a burden on the family -possible nursing home placement A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Absolute bed rest in a quiet, non-stimulating environment The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? Provide a board of commonly used needs and phrases. A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the client's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the client's plan of care? Maintain the client on complete bed rest. The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? impaired memory A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a
newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? Risk for caregiver role strain related to increased client care needs A client at an extended-care facility who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include Walking the client in the facility yard during the day A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? "Evidence shows that there are changes in nerve cells and brain chemicals."
Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response? Assess the grandmother for adventitious lung sounds A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to: wander You are admitting a 30-year-old who has a hearing impairment. The client is accompanied by family members. What information would be important to ask the family members to help you care for your client? The client's preferred method of communication Which is a correct rationale for encouraging a client with otitis externa to eat soft foods? Chewing may cause discomfort An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate?
"Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion" Nursing students are reviewing statistics related to the older adult population and leading causes of death in this age group. The students demonstrate understanding of this information when they rank the following conditions in the order from highest to lowest. -heart disease -malignant neoplasms -cerebrovascular disease -COPD -alzheimer's disease -diabetes A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should incorporate the client's toileting schedule into the pattern of his wandering A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on
A patient with irritative and obstructive bladder symptoms has an enlarged prostate on digital rectal examination (DRE) and an extremely high PSA level. The nurse will anticipate that the patient will need teaching about transrectal ultrasonography (TRUS). A patient undergoing a TURP returns from surgery with a three- way urinary catheter with continuous bladder irrigation in place.The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to instill 50 ml of saline with a bulb syringe to remove the clots. The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? "The irrigation is needed to keep the catheter from being occluded by blood clots." Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. An appropriate nursing intervention for this patient is to teach the patient pelvic floor muscle training.
The nurse is preparing to administer otic drops into the adults right ear. Which action should the nurse implement? Grasp the auricle and pull up and out when putting drops in the ear A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction is primarily: "Provides comfort by reducing muscle spasms and provides fracture immobilization." A patient is scheduled for a right tympanoplasty. Which statement indicated the client understands the preop teaching concerning the surgery? If I have to sneeze or blow my nose, I will do it with my mouth open. Mr. Claus has chronic renal failure and CAD from a diet rich in hot chocolate and heavy cream. Which of the following lab values are of most concern? Glomerular filtration rate of 28 ml/min. The primary nurse in the neuro unit is very busy. Which nursing task must be implemented first? Obtain a tracheostomy tray for a client with a C4 SCI who is exhibiting air hunger
When assessing the activity-exercise pattern of a patient with chronic vertigo syndrome, the nurse notes that the patient states,"I love to run for exercise, and I usually run five or six times a week, but now I feel dizzy when I run." Which action should be included in the plan of care? Developing an exercise program that gradually increases time spent running A patient is prepared for discharge following outpatient cataract surgery. To evaluate whether the patient understands the postoperative regimen and procedures, the nurse asks the patient to demonstrate administration of eye drops A patient who had cataract extraction and intraocular lens implantation the previous day calls the eye clinic and gives the nurse all of the following information. Which information will be of most concern to the nurse? The patient has eye pain rated at a 5 (on a 0-10 scale). The 22 year old client with a severe head injury is admitted to the critical care unit. Some of the client's friends come to the nurses station requesting information. Which action would be most appropriate by the nurse? Explain that no information can be shared with the friends.
A patient is hospitalized with acute angle-closure glaucoma. All the following orders are received. Which will the nurse implement first? Mannitol (Osmitrol) 100 mg administered intravenously A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? Keep the patient's room darkened. Following a renal biopsy, it is important that the nurse: Test urine for microscopic bleeding with a dipstick In a patient who has a corticospinal tract lesion, the nurse should assess for extremity movement and strength When reviewing the results of a patients CSF, the nurse will notify the health care provider about: Glucose 30mg/dl. A male with CRF is admitted with severe infection and depression & anemia. The wife asks about the nursing care. The nurse explains the rationale of treatment: His intake of protein is restricted so the kidneys can clear the body of waste
