Adult health exam 2
Ch. 26 Nearpod - Question Answers
1. The nurse is teaching a client who has been newly diagnosed with Raynaud syndrome. Which self-care strategies should the nurse include in the teaching? Select all that apply.
a. Wear gloves to protect the hands from injury when performing tasks.
b. Do not smoke, or stop smoking.
c. Reduce emotional triggers.
i. The nurse instructs clients with Raynaud syndrome to refrain from smoking, reduce emotional triggers, protect hands and feet from injury, and wear warm socks and mittens when going outdoors in cold weather. Stress on the ulnar nerve will not cause pain associated with Raynaud syndrome.
2. A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply.
a. Wound is superficial
b. Wound has an irregular border
c. Thick, tough skin around the ankles
d. Darkened skin around the lower extremities
i. Aching leg pain is a symptom of venous insufficiency. Assessment findings that indicate the client is experiencing a venous ulcer include the wound is superficial with an irregular border. Thick skin around the ankles and darkened skin around the lower extremities are additional symptoms of venous insufficiency. A pale wound base is associated with an arterial ulcer.
3. The nurse is caring for a client with upper extremity arterial disease. Which assessments will the nurse include in the client’s plan of care? Select all that apply.
a. Measure blood pressure on both arms.
b. Assess capillary refill on both arms every 2 hours.
c. Compare radial pulses on both wrists every 2 hours.
i. Arterial stenosis and occlusions occur less frequently in the upper extremities than in the legs, and cause less severe symptoms because the collateral circulation is significantly better in the arms. However symptoms of upper extremity arterial disease include arm fatigue and pain with exercise, the inability to hold or grasp objects, and possible difficulty driving. The assessment of this client includes measuring blood pressure on both upper extremities since there may be a difference of more than 15 to 20 mm Hg because of the arterial occlusion. Capillary refill should also be assessed every 2 hours along with comparing the radial pulses on both wrists every 2 hours. Activities using the affected upper extremity can cause cramping and pain. There is no evidence that the dependent position is helpful when caring for a client with upper extremity arterial disease.
4. The nurse is caring for an older adult client in cardiac rehabilitation following heart surgery. The client has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day, reporting cramp-like pain in the legs when walking that improves with rest. Which intervention will the nurse suggest alleviating this discomfort? The client's care plan should address which issue? Select all that apply.
a. Pain related to intermittent claudication
b. Peripheral arterial circulation impairment
i. Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Clients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.
Nearpod – Time to Climb – Ch. 59
1. Which nursing intervention is appropriate for a client who plans to use a hearing aid?
· Answer: Describe the various types of hearing aids that are available
2. A client with Meniere's disease has a nursing diagnosis of risk for injury related to gait disturbances and vertigo. Which of the following would be most appropriate to include in this client's plan of care?
· Answer: Sitting down at the first sign of feeling dizzy
3. A client who comes to the ambulatory care facility states, "It feels like things are moving or spinning around me." The nurse interprets this as indicating which of the following?
· Answer: Vertigo
4. 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?
· Answer: The client's preferred method of communication
5. 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?
· Answer: Write down the steps of the procedure for the patient to read before beginning the treatment.
6. A nurse is practicing within a pediatric medicine group. What can the nurse do to maintain hearing within the pediatric client base?
· Answer: Reduce frequency and severity of ear infections.
7. A dietary modification for a patient with Ménière's disease would be:
· Answer: A decrease in sodium intake to 1500 mg/day
8. The nurse is performing an assessment of a patient’s ears. When looking at the tympanic membrane, the nurse observes a healthy membrane. What should the appearance be?
· Answer: Pearly grey and translucent
9. Which terms refers to the progressive hearing loss associated with aging?
· Presbycusis
10. During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?
· Answer: Tinnitus and sensorineural hearing loss
11. A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse?
· Answer: Assess the tympanic membrane.
12. A client comes to the walk-in clinic complaining of a “bug in my ear.” What action should be taken when there is an insect in the ear?
· Answer: Instillation of mineral oil
13. The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate?
· Answer: Conductive
14. The client is having a Weber test. During a Weber test, where should the tuning fork be placed?
· Answer: In the midline of the client's skull
15. A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do?
· Answer: Stand about 1 to 2 feet away from the ear to be tested.
16. A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate?
· Answer: "You have some fluid that has collected in your middle ear but no infection."
17. The nurse is supervising a family member who instilling ear drops into the client’s ear. Which of the following statements, made by the family member, would require further nursing instruction?
· Answer: “These drops are cold from being on the windowsill.”
18. A mother brings her daughter to the clinic for an evaluation because the child is complaining of ear pain. Which of the following would lead the nurse to suspect that the child is experiencing otitis externa and not otitis media?
· Answer: Aural tenderness
19. Which statement describes benign paroxysmal positional vertigo (BPPV)?
· Answer: The vertigo is usually accompanied by nausea and vomiting.
20. The nurse is assessing a client for objective symptoms of hearing difficulties. Which symptom leads the nurse to take alternate measures to ensure client understanding of teaching?
· The client leans forward and turns the head.
21. A client has undergone a myringotomy. The nurse interprets this as which of the following?
· Answer: Incision of the eardrum
22. The nurse is caring for a client with recurrent ear infections. The nurse assesses the client for further infectious processes traveling deeper into the tissue and becoming more lethal. Which infection, originated in the ear, is of most concern?
· Answer: Meningitis
23. A client is being discharged home after surgery involving the middle ear. Which of the following client statements demonstrates understanding of the instructions?
· Answer: If I sneeze or cough during the first few weeks, I should keep my mouth open
24. A patient has serous otitis media with significant hearing loss in the right ear. The patient states, “I have not been able to hear for 2 months.” What procedure does the nurse anticipate preparing the patient for?
· Answer: Myringotomy
25. The nurse caring for a client with Ménière's disease needs to assist with what when the client is experiencing an attack?
· Answer: ADL’s
c.
Ch. 59 Nearpod Question Answer
1. Which of the following tests uses a tuning fork between two positions to assess hearing?
a. Answer: Rinne
b. In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air conduction of sound and bone conduction of sound. The whisper test involves covering the untested ear and whispering from a distance of 1 or 2 feet from the unoccluded ear; it assesses the ability of the patient to repeat what was whispered. The watch tick test relies on the ability of the patient to perceive the high-pitched sound made by a watch held at the patient’s auricle. The Weber test uses bone conduction to test lateralization of sound.
2. 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?
a. The client's preferred method of communication
b. Some clients with hearing deficits learn sign language, a method for communication that uses a hand-spelled alphabet and word symbols. Clients also learn speech reading, also called lip reading. Knowing when the client lost their hearing, or what allergies the client has or how much the client weighs will not help you communicate, thereby, care for the client better.
3. The nurse is assessing the auricles of a patient. When the left auricle is manipulated, the patient complains of pain. What does this finding indicate?
a. The patient may have acute external otitis.
b. Manipulation of the auricle does not normally elicit pain. If this maneuver is painful, acute external otitis is suspected
4. Which statement describes benign paroxysmal positional vertigo (BPPV)?
a. The vertigo is usually accompanied by nausea and vomiting.
b. The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired.
5. A client with Meniere's disease has a nursing diagnosis of risk for injury related to gait disturbances and vertigo. Which of the following would be most appropriate to include in this client's plan of care?
a. Sitting down at the first sign of feeling dizzy
b. BPPV is a brief period of incapacitating vertigo that occurs when the position of the client's head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however, generally, hearing impairment does not occur. The onset of BPPV is sudden and followed by a predisposition to positional vertigo, usually for hours to weeks but occasionally months or years. BPPV is thought to be caused by the disruption of debris within the semicircular canal. This debris forms from small crystals of calcium carbonate from the inner ear structure, the utricle. BPPV is frequently stimulated by head trauma, infection, or other events.
Ch. 58 Nearpod Question Answers
1. The nurse is testing an older adult client with the Snellen chart. What is the nurse testing the client for?
a. Visual acuity
b. The Snellen eye chart is a simple screening tool for determining visual acuity, the ability to see far images clearly.
2. A client has noticed needing to hold printed material at arms length to make the print readable. What is the term used to describe this visual condition?
a. Presbyopia
b. Presbyopia is associated with aging and results in difficulty with near vision. People with presbyopia hold reading material or handwork at a distance to see it more clearly.
3. A client who is blind is awaiting elective surgery. What should the nurse do to promote this client's control over their hospital environment?
a. Ask the client where to store his or her self-care items.
b. Ask the client's preference for where to store hygiene articles and other objects needed for self-care. Involving the client promotes his or her control over the environment. Personal care items should be kept in the same location at all times to provide the client with the ability to locate toiletries easily. At mealtime, describe where food is on the plate using the positions on the face of a clock. This measure assists the client to identify the location of food. Allow the client to open containers and offer help if needed. Having a choice facilitates independence.
4. After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. Which client statement indicates that the outcome of the teaching plan has been met?
a. "I should avoid pulling or pushing any object that weighs more than 15 lbs."
b. After cataract surgery, the client needs to avoid lifting, pulling, or pushing any object that weighs more than 15 pounds to prevent putting excessive pressure on the surgical site.
5. Prior to an eye exam for possible macular degeneration, the nurse completes a history of symptoms. The nurse is aware that a diagnostic sign of age-related dry macular degeneration is:
a. The appearance of tiny, yellow spots in the field of vision.
b. Drusen are tiny yellow spots that patients who have dry AMD report. Loss of peripheral vision is related to glaucoma. Painless, flashing lights is related to retinal detachment. Blurred vision is related to cataracts.
Ch. 65 Nearpod Question Answers
1. The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?
a. Increased intracranial pressure
b. Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that volume either increased of decreased is an issue.
2. The nurse and a nursing student are admitting a client with a malignant glioma brain tumor preoperatively for resection of the tumor. The nursing student asks the nurse, " I was told these types of tumors have a very poor prognosis. Why is the tumor being resected?" Which rationale for this intervention is true?
a. "Surgical resection of the tumor will decrease intracranial pressure."
b. For clients with malignant glioma, complete removal of the tumor and cure are not possible, but the rationale for resection includes relief of intracranial pressure, removal of any necrotic tissue, and reduction in the bulk of the tumor, which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy. Due to the poor prognosis with this tumor, it is not likely that the surgical resection is considered a life-saving measure. Rather the surgical intervention is a means to manage symptoms in the palliative phase of the client's disease. Surgical resection does not eliminate the need for chemotherapy. Due to the malignant nature of this tumor, the surgery will not completely eliminate the tumor, but chemotherapy can be administered to eradicate or slow further cell growth to promote comfort in the palliative phase of the disease. In the case of this client, reversal of paralysis caused by brain tumor compression 6 months ago is not possible. This would not be the aim of the surgical resection.
3. A nurse is assessing a client with Parkinson's disease. Which of the following would the nurse expect to find?
a. Slowing of activity
b. Clients with Parkinson's disease typically manifest bradykinesia (slowing of all active movement), a propulsive, forward leaning gait, tremors that disappear with active movement, and muscle rigidity.
4. A nurse suspects that a client has Huntington disease based on the demonstration of which prominent assessment finding?
a. Chorea
b. The most prominent clinical features of Huntington disease include chorea, intellectual decline, and often emotional disturbance. As the disease progresses, speech becomes slurred, gait becomes disorganized, and cognitive function is altered with dementia.
5. A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition?
a. Impaired verbal communication
b. Impaired communication is an appropriate nursing diagnosis; the voice in clients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in clients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.
Ch. 61 Seizures/Headaches
KAHOOT Answers
1. What is the primary cause of seizures in the gerontological population?
Correct Answer: Cerebrovascular disease
2. Question: What neurotransmitter is released by excitatory neurons?
Correct Answer: D. Glutamate
3. Question: Inhibitory neurons release which neurotransmitter?
Correct Answer: A. GABA
4. Question: What imbalance between neurons can lead to seizure activity?
Correct Answer: A. Increased excitatory neurons
5. Question: Which medication stimulates GABA receptors to decrease brain excitation?
Correct Answer: D. Lorazepam
6. Question: What is the leading cause of seizures in the pediatric population?
Correct Answer: B. Fever
7. Question: What is the hallmark finding in absence (petit-mal) seizures?
Correct Answer: B. Staring
8. Question: Which stage of a seizure includes altered vision or hearing seconds to minutes prior to the seizure as reported by the patient?
Correct Answer: A. Aura
9. Question: What seizure type is most common and affects both sides of the brain?
Correct Answer: B. Tonic-clonic – Generalized seizure
10. Question: What characterizes the postictal phase for absence seizures?
Correct Answer: C. Immediate recovery
11. Question: What is the main trigger for seizures related to epilepsy?
Correct Answer: D. Undermedicated
12. Question: What fast-acting medication is commonly used as an antiseizure medication in status epilepticus ?
Correct Answer: C. Diazepam
13. Question: What precaution should be taken during a seizure to protect the patient?
Correct Answer: D. Assist to side lying
14. Question: What is the primary goal of seizure precautions?
Correct Answer: A. Preventing injury
15. Question: What medication may be used as abortive therapy for recurrent migraines?
Correct Answer: C. Sumatriptan
16. Question: Which type of headache is characterized by severe pain around one eye with tearing and a runny nose?
Correct Answer: C. Cluster headache
17. Question: When evaluating a headache, what does the term "First" refer to?
Correct Answer: C. First time headache
18. Question: What is a common diagnostic test for evaluating headaches?
Correct Answer: C. MRI/CT
19. Question: What is the purpose of prophylactic medications in managing headaches?
Correct Answer: C. Prevent recurrent migraines
20. Question: What is the primary symptom of Complex Partial seizures?
Correct Answer: B. Unawareness
21. Question: A patient has been prescribed Valproate for seizure management. What significant side effect should the nurse monitor for and educate the patient about?
Correct Answer: D. Pancreatitis
22. Question: What is the primary goal during the postictal phase of a seizure?
Correct Answer: D. Preventing complications
23. Question: A patient is having a generalized seizure. At what point does the nurse recognize the situation requires intervention?
Correct Answer: B. Seizures lasting for more than 5 minutes
24. Question: What lifestyle change may help prevent migraines?
Correct Answer: B. Stress reduction
25. Question: For a patient with a migraine history prescribed Sumatriptan, what instructions should the nurse provide about its use?
Correct Answer: A. Take the medication at the onset of aura
26. Question: What is an expected clinical manifestation during the immediate postictal phase for a generalized grand-mal seizure?
Correct Answer: B. Sore and sleepy
27. Question: Which type of seizure may involve lip smacking and rubbing hands together?
Correct Answer: B. Complex-Partial
28. Question: What is the primary reason for administering antiseizure medication Phenytoin?
Correct Answer: C. Tonic-clonic seizures
29. Question: When implementing seizure precautions for a patient on CIWA (alcohol withdrawal) protocol, which intervention should the nurse prioritize?
Correct Answer: D. Removing restrictive clothing and objects
30. Question: Which headache type is characterized by recurrent attacks of severe, headaches with strong familial tendency?
Correct Answer: A. Migraine
31. Question: What is the primary purpose of the Vagus Nerve Stimulator (VNS) in the treatment of seizures?
Correct Answer: D. Providing electrical stimulation to reduce seizure activity
32. Question: What is the primary symptom of a Tonic seizure?
Correct Answer: C. Body stiffening
33. Question: Which type of headache is most likely to cause significant discomfort around one eye and a runny nose?
Correct Answer: C. Cluster headache
34. Question: A patient is diagnosed with cluster headaches. What should the nurse emphasize about their characteristics and triggering events?
Correct Answer: D. Cluster headaches may be triggered by eating, talking, or temperature changes.
35. Question: What comfort measures should the nurse prioritize to alleviate the patient's discomfort when they are experiencing a migraine?
Correct Answer: C. Promote a quiet, dark room environment.
Ch. 64 Nearpod Question Answers
1. The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for
a. Answer: renal complications related to acyclovir therapy.
b. Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse, treatment with acyclovir should continue for up to 3 weeks.
2. The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
a. Answer: Headache and nuchal rigidity
b. Headache and fever are the initial symptoms of meningitis. Nuchal rigidity can be an early sign. Photophobia is also a well-recognized sign in meningitis. Ptosis and diplopia are usually seen with myasthenia gravis. Hyporeflexia in the legs is seen with Guillain-Barre syndrome.
3. A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?
a. Answer: Initiate isolation precautions.
b. Explanation: The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.
4. A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
a. Avoid hot temperatures.
b. Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue. A balance of rest and activity is a good strategy, but avoidance of any physical activity is not recommended. Avoidance of all alcohol is a good strategy. Analgesics may be required for pain management.
5. The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client?
a. Providing ventilatory assistance
b. Providing ventilatory assistance takes precedence in the immediate management of the client with myasthenic crisis. It may be necessary to suction secretions and/or provide tube feedings, but they are not the priority for this client. ABG analysis will be done, but this is not the priority.
6. The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?
a. Muscle weakness and hyporeflexia of the lower extremities.
b. Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.