EYES, EARS, MUSCULOSKELETAL SYS, NEURO SYS, SKIN, ENDO

The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?

A) Provide instructions in simple, clear terms.

B) Introduce herself in a firm, loud voice at the doorway of the room.

C) Lightly touch the patient's arm and then introduce herself.

D) State her name and role immediately after entering the patient's room.

D) State her name and role immediately after entering the patient's room.

Rationale: There are several guidelines to consider when interacting with a person who is

blind or has low vision. Identify yourself by stating your name and role, before touching

or making physical contact with the client. When talking to the person, speak directly at

him or her using a normal tone of voice. There is no need to raise your voice unless the

person asks you to do so and there is no particular need to simplify verbal instructions.

During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?

A) Ask the social worker to investigate alternative housing arrangements.

B) Ask the social worker to investigate community support agencies.

C) Encourage the patient to explore surgical corrections for the vision problem.

D) Arrange for referral to a rehabilitation facility for vision training.

B) Ask the social worker to investigate community support agencies.

Rationale: Managing low vision involves magnification and image enhancement through

the use of low-vision aids and strategies and referrals to social services and community

agencies serving those with visual impairment. Community agencies offer services to

clients with low vision, which include training in independent living skills and a variety of

assistive devices for vision enhancement, orientation, and mobility, preventing clients

from needing to enter a nursing facility. A rehabilitation facility is generally not needed by

the clients to learn to use the assistive devices or to gain a greater degree of

independence. Surgical options may or may not be available to the client.

The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patient's immediate family members to undergo clinical examinations how often?

A) At least monthly

B) At least once every 2 years

C) At least once every 5 years

D) At least once every 10 years

B) At least once every 2 years

Rationale: Glaucoma has a family tendency and family members should be encouraged to undergo examinations at least once every 2 years to detect glaucoma early. Testing on a monthly basis is excessive.

A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patient's care?

A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium

B) Eyeglasses or magnifying lenses

C) Corticosteroid eye drops

D) Surgical intervention

D) Surgical intervention

Rationale: Surgery is the treatment option of choice when the client's functional and

visual status is compromised. No nonsurgical (medications, eye drops, eyeglasses)

treatment cures cataracts or prevents age-related cataracts. Studies recently have found

no benefit from antioxidant supplements, vitamins C and E, beta-carotene, or selenium.

Corticosteroid eye drops are prescribed for use after cataract surgery; however, they

increase the risk for cataracts if used long-term or in high doses. Eyeglasses and

magnification may improve vision in the client with early stages of cataracts, but have

limitations for the client with impaired functioning

A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this patient?

A) Generously flush the affected eye with a dilute antibiotic solution.

B) Generously flush the affected eye with normal saline or water.

C) Apply a patch to the affected eye.

D) Apply direct pressure to the affected eye.

B) Generously flush the affected eye with normal saline or water.

Rationale: Chemical burns of the eye should be immediately irrigated with water or

normal saline to flush the chemical from the eye. Antibiotic solutions, lubricant drops, and

other prescription drops may be prescribed at a later time. Application of direct pressure

may extend the damage to the eye tissue and should be avoided. Patching will be

incorporated into the treatment plan at a later time to assist with the process of

re-epithelialization, but at this point in the care of the client, patching will prevent

irrigation of the eye.

The nurse is administering eye drops to a patient with glaucoma. After instilling the patient's first medication, how long should the nurse wait before instilling the patient's second medication into the same eye?

A) 30 seconds

B) 1 minute

C) 3 minutes

D) 5 minutes

D) 5 minutes

Rationale: A 5-minute interval between successive eye drop administrations allows for

adequate drug retention and absorption. Any time frame less than 5 minutes will not

allow adequate absorption.

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding?

A) This is a normal aging process of the eye.

B) Glasses will minimize this phenomenon.

C) The patient may be exhibiting signs of glaucoma.

D) This may be a result of weakened ciliary muscles.

A) This is a normal aging process of the eye.

Rationale: As the body ages, the perfect gel-like characteristics of the vitreous humor are

gradually lost, and various cells and fibers cast shadows that the client perceives as

floaters. This is a normal aging process in most cases

A patient's ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patient's discharge education?

A) Disturbed body image

B) Chronic pain

C) Ineffective protection

D) Unilateral neglect

A) Disturbed body image

The nurse's assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patient's visual acuity?

A) Assess the patient's vision using a Snellen chart.

B) Determine whether the patient is able to see the nurse's hand motion.

C) Perform a detailed examination of the patient's external eye structures.

D) Palpate the patient's periocular regions.

B) Determine whether the patient is able to see the nurse's hand motion.

Rationale: If the client cannot count fingers, the examiner raises one hand up and down

or moves it side to side and asks in which direction the hand is moving. An inability to

count fingers precludes the use of a Snellen chart. Palpation and examination cannot

ascertain visual acuity.

The nurse on the medical-surgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications?

A) Potassium-sparing diuretics

B) Cholinergics

C) Antibiotics

D) Loop diuretics

B) Cholinergics

Rationale: Cholinergics are used in the treatment of glaucoma. The action of this

medication is to increase aqueous fluid outflow by contracting the ciliary muscle and

causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not

used in the management of glaucoma

A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action?

A) Instill the medication in the conjunctival sac.

B) Maintain a supine position for 10 minutes after administration.

C) Keep the eyes closed for 1 to 2 minutes after administration.

D) Apply the medication evenly to the sclera

A) Instill the medication in the conjunctival sac.

Rationale: Eye drops should be instilled into the conjunctival sac, where absorption can

best take place, rather than distributed over the sclera. It is unnecessary to keep the

eyes closed or to maintain a supine position after administration

A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate?

A) Holding the next dose and notifying the physician

B) Treating the patient for an allergic reaction

C) Suggesting that the patient put on her glasses

D) Explaining that this is an expected adverse effect

D) Explaining that this is an expected adverse effect

The nurse should recognize the greatest risk for the development of blindness in which of the following patients?

A) A 58-year-old Caucasian woman with macular degeneration

B) A 28-year-old Caucasian man with astigmatism

C) A 58-year-old African American woman with hyperopia

D) A 28-year-old African American man with myopia

A) A 58-year-old Caucasian woman with macular degeneration

A 6-year-old child 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?

A) Handwashing can prevent the spread of the disease to others.

B) The importance of compliance with antibiotic therapy

C) Signs and symptoms of complications, such as meningitis and septicemia

D) The likely need for surgery to prevent scarring of the conjunctiva

A) Handwashing can prevent the spread of the disease to others.

Rationale: Flashing lights in the visual field is a common symptom of retinal detachment.

Clients may also report spots or floaters or the sensation of a curtain being pulled across

the eye. Retinal detachment is not associated with eye pain, loss of color vision, or

colored halos around lights.

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?

A) Arrange for the administration of prophylactic antibiotics to unaffected residents.

B) Instill normal saline into the eyes of affected residents two to three times daily.

C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing.

D) Isolate affected residents from residents who have not developed conjunctivitis.

D) Isolate affected residents from residents who have not developed conjunctivitis.

Rationale: To prevent spread during outbreaks of conjunctivitis caused by adenovirus,

health care facilities must set aside specified areas for treating clients diagnosed with or

suspected of having conjunctivitis caused by adenovirus. Antibiotics and saline flushes

are ineffective and normally there is no need to perform testing of individuals lacking

symptoms.

A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do?

A) Call the physician and ask for the order to be confirmed.

B) Follow the order because this position will help keep the retinal repair intact.

C) Instruct the patient to maintain this position to prevent bleeding.

D) Reposition the patient after the first dressing change

B

Rationale: For care of the client after surgical retina detachment repair, postoperative positioning of the client is critical because the injected bubble must float into a position

overlying the area of detachment, providing consistent pressure to reattach the sensory

retina. The client must maintain a prone position that would allow the gas bubble to act

as a tamponade for the retinal break. Clients and family members should be made aware

of these special needs beforehand so that the client can be made as comfortable as

possible. It would be inappropriate to deviate from this order and there is no obvious

need to confirm the order.

A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action?

A) Reassure the patient that this is an age-related change in vision.

B) Arrange for the patient to have her visual acuity assessed.

C) Arrange for the patient to be assessed for macular degeneration.

D) Facilitate tonometry testing.

C

Rationale: The Amsler grid is a test often used for clients with macular problems, such as

macular degeneration. Distortions would not be attributed to age-related changes and

there is no direct need for testing of intraocular pressure or visual acuity.

A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?

A) "You know, you are getting older now and we change as we get older."

B) "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry."

C) "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation."

D) "The eye gets shorter, back to front, as we age and it changes how we see things."

C

ANS: C

Rationale: As a result of a loss of accommodative power in the lens with age, many adults

require bifocals or other forms of visual correction. This is not attributable to a change in

the shape of the ocular globe. The nurse should not dismiss or downplay the client's

concerns.

The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patient's health education?

A) The need to limit exposure to bright light

B) The need to maintain a low Fowler's position when removing the prosthesis

C) The need to perform thorough hand hygiene before handling the prosthesis

D) The need to apply antiviral ointment to the prosthesis daily

C

Rationale: Proper hand hygiene must be observed before inserting and removing an ocular prosthesis. There is no need for a low Fowler position or for limiting light exposure.

Antiviral ointments are not routinely used.

Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis?

A) Pilocarpine

B) Penicillin

C) Ganciclovir

D) Gentamicin

C

Rationale: The surgically implanted sustained-release insert of ganciclovir enables higher

concentrations of ganciclovir to reach the CMV retinitis. Pilocarpine is a muscarinic agent

used in open-angle glaucoma. Gentamicin and penicillin are antibiotics that are not used

to treat CMV retinitis.

A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond?

A) "Overuse of these drops could soften your cornea and damage your eye."

B) "You could lose the peripheral vision in your eye if you used these drops too much."

C) "I'm sorry, this medication is considered a controlled substance and patients cannot take it home."

D) "I know these drops will make your eye feel better, but I can't let you take them home."

A

Rationale: Most clients are not allowed to take topical anesthetics home because of the

risk of overuse, even though they are not classified as controlled substances. Clients with

corneal abrasions and erosions experience severe pain and are often tempted to overuse

topical anesthetic eye drops. Overuse of these drops results in softening of the cornea.

Prolonged use of anesthetic drops can delay wound healing and can lead to permanent

corneal opacification and scarring, resulting in visual loss. The nurse must explain the

rationale for limiting the home use of these medications.

A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patient's medication regimen. The patient states that she is eager to "beat this disease" and looks forward to the time that she will no longer require medication. How should the nurse best respond?

A) "You have a great attitude. This will likely shorten the amount of time that you need medications."

B) "In fact, glaucoma usually requires lifelong treatment with medications."

C) "Most people are treated until their intraocular pressure goes below 50 mm Hg."

D) "You can likely expect a minimum of 6 months of treatment."

B

Rationale: Glaucoma requires lifelong pharmacologic treatment. Normal intraocular

pressure is between 10 and 21 mm H

An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response?

A) Ask if the patient has been using OTC vasoconstrictors.

B) Instruct the patient to repeat the test at different times of the day when at home.

C) Arrange for the patient to visit his ophthalmologist.

D) Encourage the patient to adhere to his prescribed drug regimen.

C

Rationale: With a change in the client's perception of the grid, the client should notify the

ophthalmologist immediately and should arrange to be seen promptly. This is a priority

over encouraging drug adherence, even though this is also important. Vasoconstrictors

are not a likely cause of this change and repeating the test at different times is not

relevant.

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply.

A) Diabetic retinopathy

B) Trauma

C) Macular degeneration

D) Cytomegalovirus

E) Glaucoma

A,C,E

Rationale: The most common causes of blindness and visual impairment among adults 40

years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and

cataracts. Therefore, trauma and cytomegalovirus are incorrect.

25. The nurse is assessing a new adult client. What characteristic of this client's status

should the nurse identify as increasing the client's risk for glaucoma?

A) The patient uses OTC NSAIDs.

B) The patient has a history of stroke.

C) The patient has diabetes.

D) The patient has Asian ancestry.

C

Rationale: Diabetes is a risk factor for glaucoma, but Asian ancestry, NSAIDs, and stroke

are not risk factors for the disease.

The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision?

A) "I'm planning to avoid exposure to direct sunlight on my next vacation."

B) "I've never exercised regularly, but I'm going to start working out at the gym daily."

C) "I'm planning to talk with my pharmacist to review my current medications."

D) "I'm certainly going to keep a close eye on my blood pressure from now on."

D

Rationale: Hypertension is a major cause of vision loss, exceeding the significance of

inactivity, sunlight, and adverse effects of medications

A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?

A) Explain the location of items using clock cues.

B) Explain that each of the items on the tray is clearly separated.

C) Describe the location of items from the bottom of the plate to the top.

D) Ask the patient to describe the location of items before confirming their location.

A

Rationale: The food tray's composition is likened to the face of a clock. It is unreasonable

to expect the client to describe the location of items or to state that items are separated.

A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patient's room?

A) That a commode is always available at the bedside

B) That all furniture remains in the same position

C) That visitors do not leave items on the bedside table

D) That the patient's slippers stay under the bed

B

Rationale: All articles and furniture must remain in the same positions throughout the

client's hospitalization. This will reduce the client's risks for falls. Visual impairment does

not necessarily indicate a need for a commode. Keeping slippers under the bed and

keeping the bedside table clear are also appropriate, but preventing falls by maintaining

the room arrangement is a priority

A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patient's immediate postoperative recovery?

A) Teaching the patient about options for eye prostheses

B) Teaching the patient to estimate depth and distance with the use of one eye

C) Assessing and addressing the patient's emotional needs

D) Teaching the patient about his post-discharge medication regimen

C

Rationale: When surgical eye removal is unexpected, such as in severe ocular trauma,

leaving no time for the client and family to prepare for the loss, the nurse's role in

providing emotional support is crucial. In the short term, this is a priority over teaching

regarding prostheses, medications, or vision adaptation.

A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?

A) Risk factors for postoperative cytomegalovirus (CMV)

B) Compensating for vision loss for the next several weeks

C) Non-pharmacologic pain management strategies

D) Signs and symptoms of increased intraocular pressure

D

Rationale: Clients must be educated about the signs and symptoms of complications,

particularly of increasing IOP and postoperative infection. CMV is not a typical

complication and the client should not expect vision loss. Vitreoretinal procedures are not associated with high levels of pain.

A patient is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the patient's statements best demonstrates an adequate understanding?

A) "I need to call the doctor if I get nauseated."

B) "I need to call the doctor if I have a light morning discharge."

C) "I need to call the doctor if I get a scratchy feeling."

D) "I need to call the doctor if I see flashing lights."

D

Rationale: Postoperatively, the client who has undergone cataract extraction with

intraocular lens implant should report new floaters in vision, flashing lights, decrease in

vision, pain, or increase in redness to the ophthalmologist. Slight morning discharge and

a scratchy feeling can be expected for a few days. Blurring of vision may be experienced

for several days to weeks.

A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this patient's psychosocial needs, what nursing action is most appropriate?

A) Encourage the patient to focus on her use of her other senses.

B) Assess and promote the patient's coping skills during interactions with the patient.

C) Emphasize that her lifestyle will be unchanged once she adapts to her vision loss.

D) Promote the patient's hope for recovery.

B

Rationale: The nurse should empathically promote the client's coping with her loss.

Focusing on the remaining senses could easily be interpreted as downplaying the client's

loss, and recovery is not normally a realistic possibility. Even with successful adaptation,

the client's lifestyle will be profoundly affected.

When administering a patient's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal?

A) Ensure that the patient is well hydrated at all times.

B) Encourage self-administration of eye drops.

C) Occlude the puncta after applying the medication.

D) Position the patient supine before administering eye drops.

C

Rationale: Absorption of eye drops by the nasolacrimal duct is undesirable because of the

potential systemic side effects of ocular medications. To diminish systemic absorption

and minimize the side effects, it is important to occlude the puncta. Self-administration,

supine positioning, and adequate hydration do not prevent this adverse effect.

A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.

A) Application of topical antibiotic ointment

B) Maintenance of a supine position for the first 48 hours postoperative

C) Fluid restriction to prevent orbital edema

D) Administration of loop diuretics to prevent orbital edema

E) Use of an ocular pressure dressing

A,E

Rationale: Clients who undergo eye removal need to know that they will usually have a

large ocular pressure dressing, which is typically removed after a week, and that an

ophthalmic topical antibiotic ointment is applied in the socket three times daily. Fluid

restriction, supine positioning, and diuretics are not indicated.

35. A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse notes that the client has a history of dry eyes. The nurse interprets this information as indicating a problem with which structure?

A. lacrimal apparatus

B. sclera

C. cornea

D. pupil

ANS: A

Rationale: The lacrimal apparatus are located in the eyelid and inner canthus and are

essential for tear formation and drainage needed to lubricate the eyes. The sclera,

commonly known as the white of the eye, is a dense, fibrous structure that helps

maintain the shape of the eyeball and protects the intraocular contents from trauma. The

cornea is a transparent, avascular, domelike structure that covers the iris, pupil, and

anterior chamber. It is the most anterior portion of the eyeball and is the main refracting

surface of the eye. The pupil is a space that dilates and constricts in response to light.

36. A nurse is conducting an examination of a client's inner eye. When viewing the retina,

which structure(s) would the nurse identify as a retinal landmark? Select all that apply.

A. optic disk

B. macula

C. posterior chamber

D. vitreous humor

E. ciliary body

ANS: A, B

Rationale: Viewed through the pupil, the landmarks of the retina are the optic disc, the

retinal vessels, and the macula. The posterior chamber is a small space between the

vitreous and the iris. Vitreous humor is a clear, gelatinous substance which occupies

about two thirds of the eye's volume and helps maintain the shape of the eye. The ciliary

body controls accommodation through the zonular fibers and the ciliary muscles

37. A nurse is interviewing a middle-aged client at the clinic. During the interview, the

client states, "I've noticed that I keep having to move the newspaper farther away to

read it. Soon my arms will be too short!" The nurse interprets this finding as indicative of

which age-related change?

A. loss of accommodation

B. shrinkage of the vitreous body

C. meibomian gland dysfunction (MBG)

D. loss of skin elasticity

ANS: A

Rationale: Loss of accommodative power in the lens with age leads to the need to hold

reading materials at increasing distances in order to focus. Shrinkage of the vitreous

body can lead to retinal tears and detachment. Meibomian gland dysfunction can lead to

complaints related to dry eyes. Loss of skin elasticity and orbital fat can lead to lid

margins turning in or out.

38. While inspecting the external eye of a client, the nurse notes that the client's right

eyelid droops. Which term would the nurse use to document this finding?

A. ptosis

B. entropion

C. ectropion

D. presbyopia

ANS: A

Rationale: Ptosis refers to a drooping eyelid. Sometimes, the upper or lower lid turns out, referred to as ectropion, affecting closure. Additionally, the eyelid may invert; this is

termed entropion and causes irritation of the eye. Presbyopia is a term used for impaired

near vision and is often found in middle-aged and older persons.

39. A nurse is assisting the ophthalmologist who is performing direct ophthalmoscopy.

When conducting this examination, which structure would the nurse expect to be

examined last?

A. red reflex

B. vasculature

C. optic disc

D. macula

ANS: D

Rationale: The last area of the fundus to be examined is the macula, because this area is

the most sensitive to light. The examination begins with inspection of the red reflex and

then followed by the vasculature, as a large vessel becomes larger in diameter, leading to

the optic disc.

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of otitis externa?

A) Tophi on the pinna and ear lobe

B) Dark yellow cerumen in the external auditory canal

C) Pain on manipulation of the auricle

D) Air bubbles visible in the middle ear

C

Rationale: Pain when the nurse pulls gently on the auricle in preparation for an otoscopic

examination of the ear canal is a characteristic finding in clients with otitis externa. Tophi

are deposits of generally painless uric acid crystals; they are a common physical

assessment finding in clients diagnosed with gout. Cerumen is a normal finding during

assessment of the ear canal. Its presence does not necessarily indicate that inflammation

is present. Air bubbles in the middle ear may be visualized with the otoscope; however,

these do not indicate a problem involving the ear canal.

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patient's health history is most likely to be linked to the patient's hearing deficit?

A) Recent completion of radiation therapy for treatment of thyroid cancer

B) Routine use of quinine for management of leg cramps

C) Allergy to hair coloring and hair spray

D) Previous perforation of the eardrum

B

Rationale: Long-term, regular use of quinine for management of leg cramps is associated

with loss of hearing acuity. Radiation therapy for cancer should not affect hearing;

however, hearing can be significantly compromised by chemotherapy. Allergy to hair

products may be associated with otitis externa; however, it is not linked to hearing loss.

An ear drum that perforates spontaneously due to the sudden drop in altitude associated

with a high dive usually heals well and is not likely to become infected. Recurrent otitis

media with perforation can affect hearing as a result of chronic inflammation of the

ossicles in the middle ear.

A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patient's preoperative teaching?

A) The procedure is an effective, time-tested treatment for sensory hearing loss.

B) The patient is likely to experience resolution of conductive hearing loss after the procedure.

C) Several months of post-procedure rehabilitation will be needed to maximize benefits.

D) The procedure is experimental, but early indications suggest great therapeutic benefits.

B

Rationale: Stapedectomy is a very successful time-tested procedure, resulting in the

restoration of conductive hearing loss. Lengthy rehabilitation is not normally required

The nurse is providing discharge education for a patient with a new diagnosis of Ménière's disease. What food should the patient be instructed to limit or avoid?

A) Sweet pickles

B) Frozen yogurt

C) Shellfish

D) Red meat

A

Rationale: The client with Ménière disease should avoid foods high in salt and/or sugar;

sweet pickles are high in both.

Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?

A) The malleus can be visualized during otoscopic examination.

B) The tympanic membrane is pearly gray.

C) Tenderness is reported by the patient when the mastoid area is palpated.

D) Clear, watery fluid is draining from the patient's ear.

D

Rationale: For the client experiencing acute head trauma, immediately report the

presence of clear, watery drainage from the ear. The fluid is likely to be cerebrospinal

fluid associated with skull fracture. The ability to visualize the malleus is a normal

physical assessment finding. The tympanic membrane is normally pearly gray in color.

Tenderness of the mastoid area usually indicates inflammation. This should be reported,

but is not a finding indicating urgent intervention.

6. A client has been diagnosed with hearing loss related to damage of the cochlea. What

term is used to describe this condition?

A) Exostoses

B) Otalgia

C) Sensorineural hearing loss

D) Presbycusis

C

Rationale: Sensorineural hearing loss is loss of hearing related to damage of the end

organ for hearing (cochlea) or cranial nerve VIII. Exostoses refer to small, hard, bony

protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a

sensation of fullness or pain in the ear. Presbycusis is the term used to refer to the progressive hearing loss associated with aging. Both middle and inner ear age-related

changes result in hearing loss

A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level?

A) Hearing will not be affected by a decibel level in this range.

B) Hearing loss may occur with a decibel level in this range.

C) Sounds in this decibel level are not perceived to be harsh to the ear.

D) Ear plugs will have no effect on these decibel levels.

B

Rationale: Sound louder than 80 dB is perceived by the human ear to be harsh and can be

damaging to the inner ear. Ear protection or plugs do help to minimize the effects of high

decibel levels

A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient?

A) Sit or stand in front of the patient when speaking.

B) Use exaggerated lip and mouth movements when talking.

C) Stand in front of a light or window when speaking.

D) Say the patient's name loudly before starting to talk

A

Rationale: Standing directly in front of a hearing-impaired client allows him or her to

lip-read and see facial expressions that offer clues to what is being said. Using

exaggerated lip and mouth movements can make lip-reading more difficult by distorting

words

The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis?

A) External otitis is characterized by aural tenderness.

B) External otitis is usually accompanied by a high fever.

C) External otitis is usually related to an upper respiratory infection.

D) External otitis can be prevented by using cotton-tipped applicators to clean the ear.

A

ANS: A

Rationale: Clients with otitis externa usually exhibit pain, discharge from the external

auditory canal, and aural tenderness. Fever and accompanying upper respiratory

infection occur more commonly in conjunction with otitis media (infection of the middle

ear). Cotton-tipped applicators can actually cause external otitis.

A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?

A) The hearing loss will likely resolve with time after the drug is discontinued.

B) The patient's hearing loss and tinnitus are irreversible at this point.

C) The patient's tinnitus is likely multifactorial, and not directly related to aspirin use.

D) The patient's tinnitus will abate as tolerance to aspirin develops.

A

Rationale: Tinnitus and hearing loss are signs of ototoxicity, which is associated with

aspirin use. In most cases, this will resolve upon discontinuing the aspirin. Many other

drugs cause irreversible ototoxicity.

A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patient's complaint?

A) These pains are an expected finding during the first few weeks of recovery.

B) The patient's complaints are suggestive of a postoperative infection.

C) The patient may have experienced a spontaneous rupture of the tympanic membrane.

D) The patient's surgery may have been unsuccessful.

A

Rationale: For 2 to 3 weeks after surgery, the client may experience sharp, shooting

pains intermittently as the eustachian tube opens and allows air to enter the middle ear.

Constant, throbbing pain accompanied by fever may indicate infection and should be

reported to the primary care provider. The client's pain does not suggest tympanic

perforation or unsuccessful surgery

The nurse is discussing the results of a patient's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss?

A) The sound is heard better in the ear in which hearing is better.

B) The sound is heard equally in both ears.

C) The sound is heard better in the ear in which hearing is poorer.

D) The sound is heard longer in the ear in which hearing is better.

A

Rationale: A client with sensorineural hearing loss hears the sound better in the ear in

which hearing is better.

The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?

A) Maintain the irrigation fluid at a warm temperature.

B) Instill short, sharp bursts of fluid into the ear canal.

C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax.

D) Have the patient stand during the procedure.

A

Rationale: Warm water (never cold or hot) and gentle, not forceful, irrigation should be

used to remove cerumen. Too forceful irrigation can cause perforation of the tympanic

membrane, and ice water causes vomiting.

A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the patient in preparation for this test?

A) Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces?

B) Do you currently take any tranquilizers or stimulants on a regular basis?

C) Do you have a history of falls or problems with loss of balance?

D) Do you have a history of either high or low blood pressure?

B

Rationale: Electronystagmography measures changes in electrical potentials created by

eye movements during induced nystagmus. Medications such as tranquilizers,

stimulants, or antivertigo agents are withheld for 5 days before the test. Claustrophobia

is not a significant concern associated with this test; rather, it is most often a concern for

clients undergoing magnetic resonance imaging (MRI). Balance is impaired by Ménière

disease; therefore, a client history of balance problems is important, but is not relevant

to test preparation. Hypertension or hypotension, while important health problems,

should not be affected by this test.

The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time?

A) Regulating the tone and volume

B) Learning to cope with amplification of background noise

C) Constant irritation of the external auditory canal

D) Challenges in keeping the hearing aid clean while minimizing exposure to moisture

B

Rationale: Each of the answers represents a common problem experienced by clients

using a hearing aid for the first time. However, amplification of background noise is a

difficult problem to manage and is the major reason why clients stop using their hearing

aid. All clients learning to use a hearing aid require support and coaching by the nurse

and other members of the health care team. Clients should be encouraged to discuss

their adaptation to the hearing aid with their audiologist.

A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?

A) Assessing for mouth droop and decreased lateral eye gaze

B) Assessing for increased middle ear pressure and perforated ear drum

C) Assessing for gradual onset of conductive hearing loss and nystagmus

D) Assessing for scar tissue and cerumen obstructing the auditory canal

A

Rationale: The facial nerve runs through the middle ear and the mastoid; therefore, there

is risk of injuring this nerve during a mastoidectomy. When injury occurs, the client may

display mouth droop and decreased lateral gaze on the operative side. Scar tissue is a

long-term complication of tympanoplasty and therefore would not be evident during the

immediate postoperative period. Tympanic perforation is not a common complication of

this surgery.

The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patient's care?

A) Risk for disturbed sensory perception

B) Risk for unilateral neglect

C) Risk for falls

D) Risk for ineffective health maintenance

C

Rationale: Vertigo is defined as the misperception or illusion of motion, either of the

person or the surroundings. A client suffering from vertigo will be at an increased risk of

falls. For most clients, this is likely to exceed the client's risk for neglect, ineffective

health maintenance, or disturbed sensation.

A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patient's health status?

A) For some patients, these recurrent infections constitute an age-related physiologic change.

B) The patient would benefit from a temporary mobility restriction to facilitate healing.

C) The patient needs to be assessed for nasopharyngeal cancer.

D) Blood cultures should be drawn to rule out a systemic infection.

C

Rationale: A carcinoma (e.g., nasopharyngeal cancer) obstructing the eustachian tube

should be ruled out in adults with persistent unilateral serous otitis media. This

phenomenon is not an age-related change and does not indicate a systemic infection.

Mobility limitations are unnecessary.

The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should understand that this patient's health history likely includes which of the following? Select all that apply.

A) The patient was diagnosed with sensorineural hearing loss.

B) The patient's hearing did not improve appreciably with the use of hearing aids.

C) The patient has deficits in peripheral nervous function.

D) The patient's hearing deficit is likely accompanied by a cognitive deficit.

E) The patient is unable to lip-read.

A,B

Rationale: A cochlear implant is an auditory prosthesis used for people with profound

sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids.

The need for a cochlear implant is not associated with deficits in peripheral nervous

function, cognitive deficits, or an inability to lip-read

A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patient's diagnosis will be?

A) Ossiculitis

B) Ménière's disease

C) Ototoxicity

D) Labyrinthitis

D

Rationale: Labyrinthitis is characterized by a sudden onset of incapacitating vertigo,

usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus.

None of the other listed diagnoses are characterized by a rapid onset of symptoms.

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity?

A) Ensure that patients understand the differences between sensory hearing loss and conductive hearing loss.

B) Educate patients about expected age-related changes in hearing perception.

C) Educate patients about the risks associated with prolonged exposure to environmental noise.

D) Be aware of patients' medication regimens and collaborate with other professionals accordingly.

D

Rationale: A variety of medications may have adverse effects on the cochlea, vestibular

apparatus, or cranial nerve VIII. All but a few, such as aspirin and quinine, cause

irreversible hearing loss. Ototoxicity is not related to age-related changes, noise

exposure, or the differences between types of hearing loss

A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?

A) Audiometry

B) Rinne test

C) Whisper test

D) Weber test

C

Rationale: A general estimate of hearing can be made by assessing the client's ability to

hear a whispered phrase or a ticking watch, testing one ear at a time.

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?

A) Rinsing the ears with normal saline after swimming

B) Avoiding loud environmental noises

C) Instilling antibiotic ointments on a regular basis

D) Avoiding the use of cotton swabs

D

Rationale: Nurses should instruct clients not to clean the external auditory canal with

cotton-tipped applicators and to avoid events that traumatize the external canal such as

scratching the canal with the fingernail or other objects.

The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patient's plan of care?

A) The nurse should perform the Rinne and Weber tests.

B) The nurse should arrange for audiometry testing as soon as possible.

C) The nurse should collaborate with the pharmacist to assess for potential ototoxic medications.

D) No specific assessments or interventions are necessary to addressing exostoses.

D

Rationale: Exostoses are small, hard, bony protrusions found in the lower posterior bony

portion of the ear canal; they usually occur bilaterally. They do not normally impact

hearing and no treatments or nursing actions are usually necessary

The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?

A) Teach the patient about the risks of ototoxic medications.

B) Instruct the patient to protect the ear from water for several weeks.

C) Teach the patient to remove cerumen safely at least once per week.

D) Instruct the patient to protect the ear from temperature extremes until healing is complete.

B

Rationale: To prevent infection, the client is instructed to prevent water from entering the

external auditory canal for 6 weeks. Ototoxic medications and temperature extremes do

not present a risk for infection. Removal of cerumen during the healing process should be

avoided due to the possibility of trauma.

A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patient's discharge education?

A) Expected changes in facial nerve function

B) The need for audiometry testing every 6 months following recovery

C) Safe use of analgesics and antivertiginous agents

D) Appropriate use of OTC ear drops

C

Rationale: Clients require instruction about medication therapy, such as analgesics and

antivertiginous agents (e.g., antihistamines) prescribed for balance disturbance.

Over-the-counter (OTC) ear drops are not recommended and changes in facial nerve

function are signs of a complication that needs to be addressed promptly. There is no

need for serial audiometry testing

After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patient's home care?

A) Preparation of nutritious meals and avoidance of contraindicated foods

B) Ensuring the patient receives adequate rest each day

C) Helping the patient adapt to temporary hearing loss

D) Assisting the patient with ambulation as needed to avoid falling

D

Rationale: The caregiver and client are cautioned that the client may experience some

vertigo and will therefore require help with ambulation to avoid falling. The client should

not be expected to experience hearing loss and no foods are contraindicated. Adequate

rest is needed, but this is not a primary focus of home care

A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient?

A) Patient is likely unable to hear the nurse during test.

B) A person adept in sign language must be present during test.

C) Lip reading will be the method of communication that is necessary.

D) The nurse should interact with the patient like any other patient.

A

Rationale: During health care and screening procedures, the practitioner (e.g., dentist,

health care provider, nurse) must be aware that clients who are deaf or hearing impaired

are unable to read lips, see a signer, or read written materials in the dark rooms required

during some diagnostic tests. The same situation exists if the practitioner is wearing a

mask or not in sight (e.g., x-ray studies, MRI, colonoscopy).

A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?

A) Yellowish-white

B) Pink

C) Gray

D) Bluish-white

C

Rationale: The healthy tympanic membrane appears pearly gray and is positioned

obliquely at the base of the ear canal. Any other color is suggestive of a pathologic

process.

A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered?

A) Ossiculoplasty

B) Insertion of a cochlear implant

C) Stapedectomy

D) Insertion of a ventilation tube

D

Rationale: If AOM recurs and there is no contraindication, a ventilating, or

pressure-equalizing, tube may be inserted. The ventilating tube, which temporarily takes

the place of the eustachian tube in equalizing pressure, is retained for 6 to 18 months

An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply

A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously.

B) Cholesteatomas are usually the result of metastasis from a distant tumor site.

C) Cholesteatomas are often the result of chronic otitis media.

D) Cholesteatomas, if left untreated, result in intractable neuropathic pain.

E) Cholesteatomas usually must be removed surgically

C,E

Rationale: Cholesteatoma is a tumor of the external layer of the eardrum into the middle

ear, often resulting from chronic otitis media. They usually do not cause pain; however,

if treatment or surgery is delayed, they may burst or destroy the mastoid bone. They are

not normally the result of metastasis and are not self-limiting.

On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?

A) Acoustic tumor

B) Cholesteatoma

C) Facial nerve neuroma

D) Glomus tympanicum

D

Rationale: In the case of glomus tympanicum, a red blemish on or behind the tympanic

membrane is seen on otoscopy. This assessment finding is not associated with an

acoustic tumor, facial nerve neuroma, or cholesteatoma

The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?

A) "Try to induce a sneeze every 4 hours to equalize pressure."

B) "Be sure to exercise to reduce fatigue."

C) "Avoid sleeping in a side-lying position."

D) "Don't blow your nose for 2 to 3 weeks."

D

Rationale: The client is instructed to avoid heavy lifting, straining, exertion, and nose

blowing for 2 to 3 weeks after surgery to prevent dislodging the tympanic membrane

graft or ossicular prosthesis. Side-lying is not contraindicated; sneezing could cause

trauma.

An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding?

A) The patient's hearing is likely normal.

B) The patient is at risk for tinnitus.

C) The patient likely has otosclerosis.

D) The patient likely has sensorineural hearing loss.

A

Rationale: The Rinne test is useful for distinguishing between conductive and

sensorineural hearing loss. A person with normal hearing reports that air-conducted

sound is louder than bone-conducted sound.

35. A nurse is preparing a presentation for a group of elementary school parents about ways to promote the health of the ears and hearing in their children. When describing the structure and function of the ears, which structure would the nurse most likely include as part of the middle ear? Select all that apply.

A. pinna

B. tympanic membrane

C. oval window

D. cochlea

E. organ of Corti

ANS: B, C

Rationale: The middle ear contains the tympanic membrane and oval window. The pinna

is part of the external ear. The cochlea and organ of Corti are part of the inner ear

36. A older adult client comes to the clinic for an evaluation. The client says, "It just

doesn't seem like I hear as well as I used to hear." As part of the assessment, the nurse

evaluates the client's gross auditory acuity. Which test would the nurse most likely

conduct?

A. whisper test

B. Weber test

C. Rinne test

D. audiometry

ANS: A

Rationale: A general estimate of hearing can be made by assessing the client's ability to

hear a whispered phrase or a ticking watch, testing one ear at a time. The Weber and

Rinne tests may be used to distinguish conductive loss from sensorineural loss when

hearing is impaired. Audiometry is an important diagnostic test to evaluate hearing and

provides specific information about a person's hearing status.

37. A client is scheduled for audiometry to evaluate hearing. When teaching the client

about this test, which characteristic would the nurse include as being evaluated? Select

all that apply.

A. pitch

B. frequency

C. intensity

D. compliance

E. postural control capabilities

ANS: A, B, C

Rationale: When evaluating hearing, three characteristics are important: frequency,

pitch, and intensity. Frequency refers to the number of sound waves emanating from a

source per second, measured as cycles per second, or Hertz (Hz). Pitch is the term used

to describe frequency; a tone with 100 Hz is considered of low pitch, and a tone of 10,000

Hz is considered of high pitch. The unit for measuring loudness (intensity of sound) is the

decibel (dB), the pressure exerted by sound. Compliance refers to the tympanic

membrane function and is measured by a tympanogram. A platform post-urography is

used to measure postural control capabilities.

38. A nurse suspects that an older adult client may be experiencing hearing loss. Which

finding would support the nurse's suspicion? Select all that apply.

A. Dropping of word endings

B. Disinterest in conversations

C. Social withdrawal

D. Domination of conversations

E. Quick decision making

ANS: A, B, C, D

Rationale: The person who slurs words or drops word endings, or produces flat-sounding

speech, may not be hearing correctly. The ears guide the voice, both in loudness and in

pronunciation. It is easy for the person who cannot hear what others say to become

depressed and disinterested in life in general. Not being able to hear causes a person who

is hearing-impaired to withdraw from situations that might prove embarrassing. Lack of

self-confidence and fear of mistakes create a feeling of insecurity in many people who are

hearing-impaired. No one likes to say the wrong thing or do anything that might appear

foolish. Loss of self-confidence makes it increasingly difficult for a person who is

hearing-impaired to make decisions. Many people who are hearing-impaired tend to

dominate the conversation, knowing that as long as it is centered on them and they can

control it, they are not so likely to be embarrassed by some mistake.

39. A client with hearing loss is scheduled to undergo aural rehabilitation. When

describing this therapy, the nurse would include which information as the primary

purpose?

A. Increase hearing ability.

B. Maximize ability to communicate.

C. Facilitate use of a hearing aid.

D. Limit extraneous noise.

ANS: B

Rationale: If hearing loss is permanent or cannot be treated by medical or surgical

means, or if the client elects not to undergo surgery, aural rehabilitation may be

beneficial. The purpose of aural rehabilitation is to maximize the communication skills of

the person with hearing impairment. Aural rehabilitation includes auditory training,

speech reading, speech training, and the use of hearing aids and hearing guide dogs.

40. A client develops a perforated eardrum. When teaching the client about this

condition, the nurse would identify which condition as a most likely cause?

A. infection

B. otosclerosis

C. Meniere disease

D. cholesteatoma

ANS: A

Rationale: Perforation of the tympanic membrane is usually caused by infection or

trauma. Sources of trauma include skull fracture, explosive injury, or a severe blow to the

ear. Less frequently, perforation is caused by foreign objects (e.g., cotton-tipped

applicators, bobby pins, keys) that have been pushed too far into the external auditory

canal. A perforated eardrum is not associated with Meniere's disease, otosclerosis, or

cholesteatoma.

A nurse on the orthopedic unit is assessing a client's peroneal nerve. The nurse should perform this assessment by doing what action?

A. Pricking the skin between the great and second toe

B. Stroking the skin on the sole of the client's foot

C. Pinching the skin between the thumb and index finger

D. Stroking the distal fat pad of the small finger

ANS: A

Rationale: The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe. None of the other listed actions elicits the function of one of the peripheral nerves.

A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability. The nurse should focus on what health problem?

A. Osteoporosis

B. Arthritis

C. Hip fractures

D. Lower back pain

ANS: B

Rationale: The leading cause of musculoskeletal-related disability is arthritis.

A nurse is providing care for a client whose pattern of laboratory testing reveals long-standing hypocalcemia. Which other laboratory result is most consistent with this finding?

A. An elevated parathyroid hormone level

B. An increased calcitonin level

C. An elevated potassium level

D. A decreased vitamin D level

ANS: A

Rationale: In the response to low calcium levels in the blood, increased levels of parathyroid hormone prompt the mobilization of calcium and the demineralization of bone. Increased calcitonin levels would exacerbate hypocalcemia. Vitamin D levels do not increase in response to low calcium levels. Potassium levels would likely be unaffected.

A nurse is caring for a client whose cancer metastasis has resulted in bone pain. What should the nurse expect the client to describe?

A. A dull, deep ache that is "boring" in nature

B. Soreness or aching that may include cramping

C. Sharp, piercing pain that is relieved by immobilization

D. Spastic or sharp pain that radiates

ANS: A

Rationale: Bone pain is characteristically described as a dull, deep ache that is "boring" in nature, whereas muscular pain is described as soreness or aching and is referred to as "muscle cramps." Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve.

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. Which assessment findings are most consistent with this diagnosis?

A. Hot skin and a capillary refill of 1 to 2 seconds

B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin

C. Pain, diaphoresis, and erythema

D. Jaundiced skin, weakness, and capillary refill of 3 seconds

ANS: B

Rationale: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction.

A client has symptoms of osteoporosis and is being assessed during an annual physical examination. The assessment shows that the client will require further testing related to a possible exacerbation of osteoporosis. The nurse should anticipate which diagnostic test?

A. Bone densitometry

B. Hip bone radiography

C. Computed tomography (CT)

D. Magnetic resonance imaging (MRI)

ANS: A

Rationale: Bone densitometry is considered the most accurate test for osteoporosis and for predicting a fracture. As such, it is more likely to be used than CT, MRI, or x-rays.

A client injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of which tissue is the diaphysis of the femur mainly constructed?

A. Epiphyses

B. Cartilage

C. Cortical bone

D. Cancellous bone

ANS: C

Rationale: The long bone shaft, which is referred to as the diaphysis, is constructed primarily of cortical bone.

A client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of which condition?

A. Scoliosis

B. Epiphyses

C. Lordosis

D. Kyphosis

ANS: D

Rationale: Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine.

When assessing a client's peripheral nerve function, the nurse uses an instrument to prick the fat pad at the top of the client's small finger. This action will assess what nerve?

A. Radial

B. Ulnar

C. Median

D. Tibial

ANS: B

Rationale: The ulnar nerve is assessed for sensation by pricking the fat pad at the top of the small finger. The radial, median, and tibial nerves are not assessed in this manner.

The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem?

A. Osteoporosis

B. Kyphosis

C. Lordosis

D. Scoliosis

ANS: C

Rationale: The nurse documents the spinal abnormality as lordosis. Lordosis is an increase in lumbar curvature of the spine. Kyphosis is an increase in the convex curvature of the spine. Scoliosis is a lateral curvature of the spine. Osteoporosis is the significant loss of bone mass and strength with an increased risk for fracture.

A client has sustained traumatic injuries that involve several bone fractures. A fracture of what type of bone may interfere with the protection of the client's vital organs?

A. Long bones

B. Short bones

C. Flat bones

D. Irregular bones

ANS: C

Rationale: Flat bones, such as the sternum, provide vital organ protection. Fractures of the flat bones may lead to puncturing of the vital organs or may interfere with the protection of the vital organs. Long, short, and irregular bones do not usually have this physiologic function.

A client has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse perform following this procedure?

A. Wrap the joint in a compression dressing.

B. Perform passive range of motion exercises.

C. Maintain the knee in flexion for up to 30 minutes.

D. Apply heat to the knee.

ANS: A

Rationale: Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated.

During assessment, a client reports experiencing rhythmic muscle contractions when the nurse performs passive extension of the wrist. The nurse should recognize the presence of which condition?

A. Fasciculations

B. Contractures

C. Effusion

D. Clonus

ANS: D

Rationale: Clonus may occur when the ankle is dorsiflexed or the wrist is extended. It is characterized as rhythmic contractions of the muscle. Fasciculation is involuntary twitching of muscle fiber groups. Contractures are prolonged tightening of muscle groups, and an effusion is the pathologic escape of body fluid.

A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. The nurse should perform interventions to prevent what complication?

A. Muscle clonus

B. Muscle atrophy

C. Rheumatoid arthritis

D. Muscle fasciculations

ANS: B

Rationale: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results

from immobility. Lack of exercise is a risk factor for rheumatoid arthritis.

A nurse is caring for a client who has been scheduled for a bone scan. Which statement should the nurse include when educating the client about this diagnostic test?

A. "The test is brief and requires that you drink a calcium solution 2 hours before

the test."

B. "You will not be allowed fluid for 2 hours before and 3 hours after the test."

C. "You will be encouraged to drink water after the administration of the radioisotope injection."

D. "This is a common test that can be safely performed on anyone."

ANS: C

Rationale: It is important to encourage the client to drink plenty of fluids to help distribute and eliminate the isotope after it is injected. There are important contraindications to the procedure, including pregnancy or an allergy to the radioisotope. The test requires the injection of an intravenous radioisotope, and the scan is performed 2 to 3 hours after the isotope is injected. A calcium solution is not used.

A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of:

A. tonus.

B. flaccidity.

C. atony.

D. spasticity.

ANS: D

Rationale: A muscle with greater-than-normal tone is described as spastic. Soft and flabby muscle tone is defined as atony. A muscle that is limp and without tone is described as being flaccid. The state of readiness known as muscle tone (tonus) is produced by the maintenance of some of the muscle fibers in a contracted state.

The nurse's comprehensive assessment of an older adult involves the assessment of the client's gait. How should the nurse best perform this assessment?

A. Instruct the client to walk heel-to-toe for 15 to 20 steps.

B. Instruct the client to walk in a straight line while not looking at the floor.

C. Instruct the client to walk away from the nurse for a short distance and then toward the nurse.

D. Instruct the client to balance on one foot for as long as possible and then walk in a circle around the room.

ANS: C

Rationale: Gait is assessed by having the client walk away from the examiner for a short distance. The examiner observes the client's gait for smoothness and rhythm. Looking at the floor is not disallowed and gait is not assessed by observing balance on one leg. Heel-to-toe walking ability is not gauged during an assessment of normal gait.

A clinic nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture?

A. Arthrography

B. Bone scan

C. Bone densitometry

D. Arthroscopy

ANS: C

Rationale: Bone densitometry is used to detect bone density and can be used to assess the risk of fracture in osteoporosis. Arthrography is used to detect acute or chronic tears of joint capsule or supporting ligaments. Bone scans can be used to detect metastatic and primary bone tumors, osteomyelitis, certain fractures, and aseptic necrosis. Arthroscopy is used to visualize a joint.

A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding?

A. Fasciculations

B. Clonus

C. Effusion

D. Crepitus

ANS: D

Rationale: Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions. Fasciculations are involuntary twitching of muscle fiber groups. Clonus is the rhythmic contractions of a muscle. Effusion is the collection of excessive fluid within the capsule of a joint.

A client's fracture is healing and compact bone is replacing spongy bone around the periphery of the fracture. This process characterizes what phase of the bone healing process?

A. Hematoma formation

B. Fibrocartilaginous callus formation

C. Remodeling

D. Bony callus formation

ANS: C

Rationale: Remodeling occurs as necrotic bone is removed by the osteoclasts. In this phase, compact bone replaces spongy bone around the periphery of the fracture. Each of the other listed phases precedes this stage.

A 10-year-old client is growing at a rate appropriate for the client's age. Which cells are responsible for the secretion of bone matrix, which eventually results in bone growth?

A. Osteoblasts

B. Osteocytes

C. Osteoclasts

D. Lamellae

ANS: A

Rationale: Osteoblasts function in bone formation by secreting bone matrix. Osteocytes are mature bone cells, and osteoclasts are multinuclear cells involved in dissolving and resorbing bone. Lamellae are circles of mineralized bone matrix.