The nurse is performing the Weber assessment test on a client who reports hearing loss in the left ear. Which finding would indicate to the nurse the client is experiencing conductive hearing loss?
Correct answer: A
For the Weber test, the tuning fork is placed on the bridge of the forehead, nose, or teeth. In a normal test, the sound is heard equally in both ears. With unilateral conductive loss, sound is heard in the affected ear. With unilateral sensorineural loss, sound is heard in the normal or better-hearing side. In a Rinne test, the tuning fork is placed on the mastoid bone behind the ear until the client can no longer feel the vibration. The fork is then moved beside the ear. In a normal test, air conduction is greater than bone conduction. The whisper test has the client repeat what is heard while pushing on the tragus.
2
The nurse is reviewing written education with a client. The nurse notes the client squinting and moving the document close to their eyes. What assessment tool would be used to collect additional information about this patient's problem?
Correct answer: B
The Snellen chart is used to assess far vision; the Jaeger test is used for near vision. Confrontation tests assess visual field and peripheral field deficits. Ishihara cards assess for the ability to differentiate color.
3
The nurse is assessing a client who had a cerebrovascular accident for complications. Which finding observed by the nurse would indicate the client is experiencing Broca’s aphasia?
Correct answer: C
Patients with a stroke in the brain’s left hemisphere are more likely to have language deficits. Damage to the Wernicke area may lead to difficulty understanding verbal communication, called receptive aphasia. Damage to the Broca area causes problems with speaking or finding words, called expressive aphasia. The client with Broca’s aphasia has slow speech, difficulty in choosing words, and difficulty forming words. This leads to frustration as the client’s comprehension is intact. Wernicke’s aphasia is a loss of comprehension. Fluency remains but is nonsensical. Anomic aphasia leads to the inability to identify written words.
4
The nurse is assessing the client with a hearing deficit for pre-existing knowledge of hearing aid care. Which of the following statements by the client demonstrates correct care?
Correct answer: B
If the patient uses a hearing aid, check the batteries routinely and clean the earpieces or ear mold daily with mild soap and water. A whistling sound that is audible when the hearing aid is held in the hand with the power on and the volume high indicates that the battery is functioning properly. The microphone port should be cleaned with a hearing aid brush and pick. The shell and molds of the hearing aid should be cleaned with a chemical-free damp cloth.
5
The nurse is assessing a client for proper use of a prosthetic leg. Which of the following actions by the client is correct?
Correct answer: A
A stump sock is designed to redistribute pressure and wick moisture away from the skin. Prosthetics require no maintenance from the wearer outside of cleaning. Adjustments to the socket to prevent injury should be done by a therapist, prosthetist, or provider. Liners are washed and changed daily to prevent infection.
6
The nurse is assessing a client with left-sided weakness while using a cane for ambulation. Which observation by the nurse would indicate correct use of the cane?
Correct answer: D
When walking with a cane, a client should hold the cane in the hand opposite the side that needs support. The patient stands with weight evenly distributed between the feet and the cane. The cane is held on the client’s stronger side. When the client is ready to walk, the client advances the cane one step ahead of the good leg. Then, the client supports their weight on the good leg and cane and moves the weaker leg forward. Once the weaker leg is advanced, then placing weight on the cane and weaker leg, the client moves the good leg forward.
7
The nurse is caring for a client experiencing left-sided homonymous hemianopsia after a cerebrovascular accident. The client has been leaving the left side of the meal plate untouched. Which of the following interventions should be implemented to improve intake?
Correct answer: C
Homonymous hemianopsia is a condition in which a person sees only one side ― right or left ― of the visual field of each eye. The condition results from a problem in brain function rather than a disorder of the eyes themselves. The most common cause is a stroke. Clients may bump into or fail to notice objects, including food on a plate. This is a problem with vision and not will weakness or paralysis, therefore the client does not need assistance being fed. Treatment includes training the client to move the eyes purposefully and move the head and eyes to the affected side. This is known as visually scanning the environment. Moving all food to the unaffected side does not promote independence/autonomy.
8
The nurse is discussing the plan of care with an older adult client who wears hearing aids. The nurse notes the client leaning forward and asks the nurse to repeat the noise. Which action should the nurse take to assist the client?
Correct answer: B
The priority action here is to reduce background noise, which is extremely distracting to a client with hearing aids. The client should be able to see the lips of the speaker, facial expressions, and hand movements. Hearing aids, if applicable, can be checked for dead batteries, etc. Finally, any message that cannot be verbally communicated can be written/typed.
9
The nurses on a medical unit are participating in a quality improvement project to promote clients’ sleep and rest. Which of the following actions should be implemented?
Correct answer: C
Answer corrected. The document keyed this as B; the correct answer is C. The document's own rationale states that alarms are a safety feature and should not be silenced, which rules out the keyed option B. It also rules out A (admissions cannot be scheduled) and D (turning off lights raises the fall risk), leaving scheduled quiet times as the correct answer.
In this hospital, unfamiliar noises, such as people walking by or entering and leaving the room and the sounds of elevator doors, bring complaints from patients in health care facilities. Many health care facilities have made attempts to transform their patient care areas into quieter settings that facilitate rest and sleep. Attention to design features with a focus on eliminating environmental noise, providing patients with private rooms, and formal quiet times on units all are aimed at creating an environment that is conducive to good sleep. Alarms are a safety feature and should not be silenced. Admissions are nearly impossible to schedule as emergencies happen 24/7. Turning off lights may increase the risk of falls and injuries.
10
The nurse is planning care for a client with a history of sleep-wake disturbances who reports a preferred bedtime at 10 pm. The nurse notes that the vital signs are scheduled for 11 pm. Which action would be appropriate for the nurse to take?
Correct answer: A
Whenever possible, provide care during periods when the patient is normally awake. When this is not feasible, avoid waking the patient during REM sleep, when rapid eye movements can be observed. Because a patient’s need for sleep is important, examine priorities for nursing care. For example, consider whether checking a vital sign or carrying out a particular nursing measure is more important than the patient’s sleep. It is safe to assess a client’s vital signs 1 hour before the scheduled time in this situation.
11
The nurse is assisting a client with denture care. Which of the following actions is appropriate?
Correct answer: D
Dentures should be soaked in and brushed with a nonabrasive denture cleanser. Hot water may warp the plastic used to make the denture. Similarly, leaving them to air dry may cause warping. Lining the sink may prevent damage to the dentures if they are accidentally dropped.
12
The nurse is caring for a client with myopia who wears eyeglasses. The client is on supplemental oxygen via nasal cannula. Which of the following actions is appropriate?
Correct answer: B
Eyeglasses are expensive items and should be protected from damage and loss. Wrapping the glasses in a napkin increases the likelihood that they will be thrown away. Lenses should be up to prevent scratching. Myopia is near-sightedness and therefore the client may need them to ambulate and perform activities of daily living (ADLs). Glasses, along with oxygen tubing, can contribute to skin breakdown, so the skin behind the ears should be assessed regularly.
13
The nurse is evaluating the client’s use of a walker with four wheels. Which of the following findings requires intervention?
Correct answer: C
Walkers also are available with wheels on all four legs. Patients who require a larger base of support and do not rely on the walker to bear weight can use these. If full body weight is applied to this type of walker, it could roll away, resulting in a fall. Wheeled walkers are best for patients who need minimal weight bearing from the walker. All other actions are correct.
14
The nurse is evaluating the client’s denture care practices. Which of the following actions requires intervention?
Correct answer: B
Dentures should be cleaned using denture cleanser. Toothpaste may be too abrasive for the plastics in the dentures. All other practices are expected.
15
The nurse is evaluating a client’s understanding of the teaching on crutch walking. Which of the following statements indicates an understanding of the teaching?
Correct answer: D
The top of the crutches should be about 2 finger width below the armpit. Weight should be placed on the hand grips. Crutches should be routinely checked for wear and damage. Rubber crutch tips will need to be replaced when they are worn or cracked. Clients should be taught to ascend up the steps with the crutches and “good” leg first. Crutches should be at least 12 inches away from the feet to prevent falling.
16
The nurse is assessing the client with a sigmoid colostomy. The client reports frequent soft stools from the stoma. What statement by the nurse is appropriate?
Correct answer: B
Diarrhea may occasionally occur in a client with a sigmoid colostomy, however, the typical stool is firmer or more like a paste compared to a higher ostomy placement. Foods such as applesauce and bananas can help with diarrhea. Ostomy pouches should be emptied once they are half full to prevent leakage. Fluid intake should be encouraged to prevent dehydration.
17
The nurse is caring for a client who has been receiving broad-spectrum antibiotics. The client has developed frequent, watery diarrhea and a fever. Which prescription should the nurse obtain first?
Correct answer: A
Clostridium difficile is diagnosed through toxin testing of stool. Prompt diagnosis is required so treatment can begin. Probiotics, antipyretics, and a rectal tube, now known as a fecal management system, are acceptable interventions for antibiotic-associated diarrhea but are not the priority.
18
The nurse is caring for a client with chronic pain who was prescribed oxycodone extended release for pain management. The client is concerned about developing constipation. Which response by the nurse is appropriate?
Correct answer: Crationale written to fill a gap in the source
Answer corrected. The document keyed this as D; the correct answer is C. Opioids reduce bowel motility, so a bulk-forming laxative adds bulk the bowel cannot move and can worsen constipation or cause obstruction. The standard management of opioid-induced constipation is a stimulant laxative, started prophylactically rather than after symptoms appear.
Opioids slow peristalsis, so stool moves through the bowel too slowly and becomes hard and dry. A stimulant laxative such as senna acts directly on the bowel wall to restore movement and is the recommended treatment, usually started at the same time as the opioid rather than waiting for constipation to develop. A bulk-forming laxative adds mass that a slowed bowel cannot propel and may worsen the problem. Taking the medication only for severe pain undertreats chronic pain and defeats the purpose of an extended-release opioid. Dairy products do not relieve constipation and may contribute to it.
19
A nurse is preparing to perform a right eye irrigation. What action is correct?
Correct answer: Arationale written to fill a gap in the source
Irrigating solution is directed from the inner canthus toward the outer canthus so that fluid and debris drain away from the unaffected eye and away from the nasolacrimal duct, which prevents cross-contamination. Eye irrigation is a clean procedure, so clean gloves are sufficient and sterile gloves are not required. The client is positioned on the affected side, in this case the right side, so the solution drains away from the other eye. The client is asked to look up rather than to the side, which protects the cornea from the direct flow of solution.
20
The nurse is preparing to perform continuous bladder irrigation (CBI) for a client who had prostate surgery. Which action is correct for the nurse to take?
Correct answer: C
When providing continuous bladder irrigation, purge the air from the tubing to ensure that no air enters the system, similar to IV tubing. The client should be in semi-Fowler's for CBI. The catheter balloon should not be deflated, or the catheter may dislodge. When performing intermittent irrigation, the catheter may be clamped below the access port.
