Is3350 Final Exam

Rachel Martin
Group: Bed Baths and Beyond
NUR402-2 Davis
Topic Set 6

1. What is the correct procedure for performing an ophthalmoscopic examination on a client’s right eye? A) Instruct the client to look at the examiner’s nose and not move his/her eyes during the exam. B) Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner’s right eye. C) From a distance of 8 to 12 inches and slightly to the side, shine the light into the client’s pupil. D) For optimum visualization, keep the ophthalmoscope at least 3 inches from the client’s eye.
Correct Answer: C
Rationale: The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope should be set on the 0 lens to
begin and should be held in front of the examiner’s left eye when examining the client’s right eye. For optimum visualization, the ophthalmoscope should be kept within one inch of the client’s eye. 2. An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client? A) Turn off the client’s television and speak very loudly. B) Communicate in writing whenever it is possible. C) Speak very slowly while exaggerating each word. D) Face the client and speak in a normal tone of voice.
Correct Answer: D
Rationale: A hearing-impaired client frequently relies on lip reading and body language to determine what is being said. 3. A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Teaching for this client will include which of the following statements? A) Drive only when feelings of dizziness have not been experienced for several hours B) Go to the bedroom and lie down when vertigo is experienced C) Remove throw rugs and clutter in the home D) Turn the head slowly when spoken to
Correct Answer: C
Rationale: The client should maintain the home without throw rugs and in a state that is free of clutter, because the effort of trying to regain balance after slipping could trigger the onset of vertigo. 4. An adult client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse would ask about which of the following as a risk factor related to infection of the ears? A) Exposure to loud noise B) Use of drilling and other power tools C) Congenital abnormalities D) Occupational noise
Correct Answer: C
Rationale: Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the Eustachian tube. Risk factors include a young age (usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. 5. A nurse instructs a client in the use of a hearing aid. The nurse includes which of the following in the instructions? (Select all that apply) A) Check the battery to ensure that it is working before use B) Remove the hearing aid before showering C) Hearing aids do not require any care D) Use a water soluble lubricant on hearing aid before insertion
Correct Answer(s): A and B
Rationale: The battery of the hearing aid should be checked before use. The hearing aid should be removed for showering, because it should not get wet. Clean according to manufacturer’s directions. 6. A client is admitted to the hospital with an exacerbation of multiple sclerosis, which of the following data supports this diagnosis? (Select all that apply) A) Increased white matter density seen on CT scan B) Presence of plaques seen on MRI C) CSF electrophoresis shows presence of oligoclonal (IgG bands) D) Burning sensation in right arm
Correct Answer(s): A, B, C
Rationale: The answers to A, B, and C are all presenting symptoms of multiple sclerosis. 7. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Meniere’s disease. When assessing this client, the nurse expects to note:
A) Vertigo, tinnitus, and hearing loss
B) Vertigo, vomiting, and nystagmus
C) Vertigo, pain, and hearing impairment
D) Vertigo, blurred vision, and fever
Correct Answer: A
Rationale: Meniere’s disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. 8.
While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?
A) The client may be less sensitive to the effects of a neuromuscular blocking agent
B) Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage
C) Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage
D) Pancuronium and succinylcholine both require cautious administration
Correct Answer: D
Rationale: The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client isn’t less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis. 9. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?
A) Vision changes
B) Absent deep tendon reflexes
C) Tremors at rest
D) Flaccid muscles
Correct Answer: A
Rationale: Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple
sclerosis. 10. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?
A) Anxiety
B) Powerlessness
C) Ineffective denial
D) Risk for disuse syndrome
Correct Answer: B
Rationale: This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can’t perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client’s comment specifically refers to an inability to act autonomously.

Reference:
Boyd, Donna. (2011). HESI Comprehensive Review for the NCLEX-RN Examination. St. Louis, MO: Elsevier.