1.
What should the nurse include in the plan of care for a newly admitted client with an infratentorial craniotomy for a brain tumor? A. keep HOB elevated 30 -45 degree and a large pillow under the client head and shoulder B. keep the head flat with a small pillow under the nape of the neck C. assess vital signs and pupils every four hours D. flex neck every two hours to prevent stiffness ANSWER: Spoiler: B! Flat on bed for infratentorial surgery to prevent herniation; having a small pillow is adequate to promote venous drainage from the head thus limiting further increase in ICP
2. A client reports gradual painless blurring of vision. On assessment, the nurse notes a cloudy opague lens, the nurse suspects the client has: A. glaucoma B. cataracts C. retinal detachment D. diabetic retinopathy ANSWER: Spoiler: B! Cataract Glaucoma this blurred vision or halos around lights, loss of peripheral vision is often accompanied with some pain like aching or discomfort around the eyes and headache (Brunner and Sudarth, 2004, p. 1758) retinal detachment no pain; patients report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters (Suddart and Brunner, p. 1767) diabetic retinopathy deterioration of the small blood vessels that nourish the retina; may cause distorted vision; pls note that other ocular complications such as cataract and glaucoma may develop in diabetes (Suddarth and Brunner, p. 1189)
3. Which of the following risk factors would the nurse assess for in a client with glaucoma? A. family history of increased intraocular pressure, and age of 45 -65 B. history of diabetes and age greater than 50 C. female gender, cigarette smoking, age greater than 65 D. myopia, history of diabetes, and sudden severe physical exertion
ANSWER: Spoiler: A! These are common risk factors for glaucoma; other risk factors include diabetes, cardiovascular disease, migraine syndromes, nearsightedness (myopia), eye trauma, and prolonged use of topical or systemic corticosteroids (Suddart and Brunner, p. 1757) Re specific age group, in Suddart and Brunner, it merely states older age and does not specify the age; however, glaucoma is more prevalent among people older than 40 and the incidence increases with age Not D because sudden physical exertion is not a risk factor but may exacerbate the increase intraocular pressure
4. A nurse is admitting a client who reports vision loss; to determine if a client has glaucoma or a detached retina, the nurse understands that a client with glaucoma will report: A. seeing floating spots B. eye pain C. seeing flashing lights D. sudden loss of vision ANSWER: Spoiler: B! Eye pain is present with open & narrow angle glaucoma but not with a detached retinal
5. The nurse is teaching a post-op stapedectomy client, what should be included in the teaching? A. work can be resumed the next day B. gently sneeze or cough with the mouth closed C. blow the nose gently one side at a time D. resume exercise in one week ANSWER: Spoiler: C! The client should blow the nose gently one side at a time to prevent pressure changes in the ear
7. An adult patient who is in pain is on long term aspirin therapy and experiencing tinnitus, the nurse best interprets this to mean: A. the Aspirin is working correctly
B. the client ingested more medicine that was recommended C. the client has an upper GI bleed D. the is experiencing a mild overdosage ANSWER: Spoiler: D! Tinnitus is a classic sign of Aspirin overdosage, either from too much ingestion or limited excretion
8. During preoperative assessment, the nurse finds that the client has an irregular pulses, pedal edema, and cyanotic nail beds. These symptoms indicate an alteration in: A. pulmonary function B. renal function C. cardiovascular function D. liver function ANSWER: Spoiler: C! Cardiovascular function ; smoking is an important risk factor but since the patient has stopped smoking for 10 years, his risk drops to the same level as a non-smoker.
9. A major advantage of regional anesthesia is that the client: A. retains all reflexes B. remains conscious C. has retroactive amnesia D. is in the OR for a short period of time ANSWER: Spoiler: B! Patient remains conscious despite the lost or diminished of reflexes 10. The most important action of Digitalis derivatives on the heart of a client in CHF is to: A. re- establish normal heart rhythm B. increase ventricular contractility C. decrease dysrhythmias D. decrease AV node refractory period
ANSWER: Spoiler: B! Digitalis exerts a direct and beneficial effect on myocardial contraction in the failing heart. It increases ventricular contractility, increases ventricular emptying and the capacity of the heart to work thereby improving stroke volume and cardiac output. Because of improved contractility, there will be an indirect effect on slowing the HR but not to bradycardic level. Prior to administering digitalis (or digoxin in the Philippines which is more commonly used with brand name of Lanoxin), take a full-minute HR to assess for slowing of HR since an adverse effect is development of heart block. The problem with this drug is that there is a very narrow margin between the therapeutic dose and the toxic dose. Thus, we need to monitor the HR which indicates toxicity that is dose-related.
