Deck 1: Adult, and Eyes

Question 1

Which of the following clinical manifestations are the most likely indicators of perforation of the gastrointestinal tract?

A)Shortness of breath, abdominal tenderness and nausea
B)Abdominal tenderness, temperature of 101.5
C)Severe abdominal pain, distention and a board like abdomen
D)Fluid and electrolyte imbalances, hypotension, paralytic ileus

Answer 1

Severe abdominal pain, distention and a board like abdomen

Question 2

What is the main intervention that needs to occur if a patient develops a perforation of the gastro intestinal tract?

A)Surgical intervention
B)Fluid resuscitation
C)Nasogastric tube placement to low wall suction
D)Hold all food and assess for signs of bleeding

Answer 2

Surgical intervention

Question 3

A thirty seven year old male is being treated for shock related to acute Pancreatitis. The patient states that he has Paresthesia around his fingers and mouth. The nurse observes that the patient's wrists and foot are tremoring. When she applies the blood pressure cuff to the patient's arm, the entire hand and arm has spasms. What abnormality is the patient exhibiting signs and symptoms of?

A)Tetany
B)Shock
C)Chvostek's sign
D)Hypersensitivity reaction

Answer 3

Tetany

Question 4

You are administering a Snellen chart test to a patient. What results would you expect to get if your patient was legally blind?

A)20/20 vision
B)20/40 vision
C)20/60 vision
D)20/200 vision

Question 5

Your patient has been diagnosed with a hyphema following hitting their head on the steering wheel during a car accident. What position would you want to place this patient in?

A)Supine
B)Semi- fowlers
C)Lateral
D)Trendelenburg

Question 6

Your patient has arrived in the emergency department with a penetrating eye injury. You are assessing the patient. What should your first action be?

A)Remove any objects from the eye.
B)Place a patch over the eye.
C)Perform a visual acuity test.
D)Use sterile saline to irrigate the eye.

Question 7

Your patient has arrived in the emergency department with a chemical eye injury. Your first action should be to:

A)Perform a visual acuity test
B)Use sterile saline to irrigate the eye
C)Place antibiotic ointment in the eye
D)Place a patch over the eye

Question 8

You are caring for a patient who has come into the emergency department with a foreign body in his right ear. After further investigation you determine that the foreign object is an insect. What intervention would the physician order first for this client?

A)Sterile normal saline irrigation
B)Diluted alcohol irrigation
C)Antibiotic ear drops
D)Corticosteroids ointment

Question 9

When caring for a patient what sign would indicate that he might have a basal skull fracture?

A)The auditory canal has purulent drainage.
B)The auditory canal has bloody or clear drainage.
C)Epistaxis
D)Periorbital edema

Question 10

You are caring for a patient who complains of tinnitus. What part of the ear do you suspect is the most likely cause of the patient's complaint?

A)External ear
B)Middle ear
C)Inner ear
D)Auricle

Question 11

You are caring for a patient who has had a right eye cataract removal. What discharge instruction would you want to include in the plan of care?

A)Do not sleep on right side.
B)Do not sleep on left side.
C)Do not sleep with head elevated.
D)Do wear glasses until physician says it is okay.

Question 12

You have delegated the care of an older patient with hearing loss to a nursing assistant. You tell the nursing assistant that patients with this diagnosis:

A)Are often distracted.
B)Respond better to low pitched sounds.
C)Have middle ear changes.
D)Develop moist cerumen production.

Question 13

The most appropriate action by the nurse who is preparing to communicate with an older patient who has hearing loss is:

A)Stand in front of the patient.
B)Exaggerate lip movements.
C)Obtain a sign language interpreter.
D)Pantomime and write the patient notes.

Question 14

Which of the following assessments would make the nurse suspect that a child has strabismus?

A)Tilts head to see
B)Turns head to see
C)Does not respond when spoken to
D)Has difficulty hearing

Question 15

You are caring for a child with chlamydial conjunctivitis. What would you want to investigate if you had a patient with this diagnosis?

A)Presence of an allergy
B)Possible trauma
C)Possible sexual abuse
D)Presence of a respiratory infection

Question 16

You are caring for a child who is going to have a tonsillectomy. Which of the following laboratory results would you want to check preoperatively?

A)Prothrombin time
B)Sedimentation rate
C)Blood urea nitrogen
D)Creatinine

Question 17

You are caring for a child who will have a tonsillectomy. Which of the following would increase the child's risk of aspiration during surgery?

A)Difficulty swallowing
B)Loose teeth
C)Bleeding
D)Exudate in the throat

Question 18

You are caring for the child who has had a tonsillectomy. The physician has written postoperative orders. Which of the following orders would the nurse question?

A)Clear, cool liquids when awake
B)No milk or milk products
C)Monitor for bleeding
D)Suction every 2 hours

Question 19

After a tonsillectomy, your patient begins to vomit. What intervention should be your priority?

A)Administer an antiemetic
B)Turn the patient to the side
C)Notify the physician
D)Maintain the patient's "nothing by mouth" status

Question 20

When caring for a patient with glaucoma, which of the following symptoms would you not expect to see on the patient's chart?

A)Severe eye pain
B)Frequent pink-eye infections
C)Blurred vision
D)Nausea and vomiting

Question 21

Which of the following orders would the physician prescribe for the patient with retinal detachment?

A)Bathroom privileges
B)Head of bed up 45 degrees
C)Eye patch to affected eye
D)Dark glasses to read or watch television

Question 22

What is the accurate procedure for performing a confrontational peripheral vision test?

A)Both examiner and patient cover the same eye and stare at each other while an object is brought into the line of sight.
B)Examiner and patient cover opposite eyes and stare at each other while an object is brought into the line of sight.
C)The patient is asked to discriminate numbers from a chart composed of colored dots.
D)The room is darkened and the patient is asked to identify colored blocks and shapes when they appear in the visual field.

Question 23

Which of the following would the nurse do when performing an otoscopic exam on a patient?

A)Pull the pinna up and back.
B)Pull the earlobe down and back.
C)Use the smallest speculum available.
D)Tilt the patients head forward and down.

Question 24

Your patient is scheduled to go for cataract surgery. What nursing diagnosis should you include in the patients plan of care?

A)Self care deficit
B)Imbalanced nutrition
C)Disturbed sensory perception
D)Anxiety

Question 25

What clinical manifestations would you see if your patient had cataracts?

A)Eye pain
B)Floating spots
C)Blurred vision
D)Diplopia

Question 26

What type of eye drops would be ordered for the patient who is being prepared for cataract surgery?

A)Osmotic diuretic
B)Miotic agent
C)Mydriatic medication
D)Thiazide diuretic

Question 27

Which of the following would be associated with detached retina?

A)Pain in the affected eye
B)Total loss of vision
C)Feeling like a curtain had fallen over their eyes
D)Yellow discoloration of the scleroses

Question 28

What intervention would you need to take if your patient had a contusion of the eyeball following a traumatic injury?

A)Notify the physician.
B)Irrigate the eye with cool water.
C)Apply ice to the affected eye.
D)Accompany the patient to the emergency room.

Question 29

What nursing action would the nurse take when caring for a patient with enucleation with bright red drainage?

A)Notify the physician.
B)Continue to monitor the drainage.
C)Document the finding.
D)Mark the drainage on the dressing.

Question 30

You are completing a hearing screening on a patient. You note that the sound lateralizes to the patient's left ear during a Weber test. What does this finding indicate?

A)A normal finding
B)Conductive hearing loss in the right ear
C)Sensorineural or conductive loss
D)Presence of nystagmus

Question 31

When caring for a hearing impaired patient what approach will facilitate communication?

A)Speak frequently.
B)Speak loudly.
C)Speak directly into the impaired ear.
D)Speak in a normal tone.

Question 32

The nurse observes that the patient's right pedal pulses are absent and the leg is swollen. The nurse's first action should be to:

A)Obtain a Glasgow Score
B)Attach an EKG
C)Order an isotonic fluid infusion through two large-bore IV lines
D)Proceed with a survey