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NSG 239 Exam1
NSG 239 Exam1
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1
Conjunctivitis can be only bilateral but never unilateral
True
False
2
What disorder is this?
Anisocoria
Astigmatism
macular degeneration
Amblyopia
3
What are the components of Sensory Reception? SATA
Gustatory
Auditory
Olfactory
Oculomotor
Visual
Tactile
4
A fluorescent stain is used to diagnose _______
Macular Degeneration
Corneal Abrasion
Primary Open Angle Glaucoma
Primary Angle-closure glaucoma
5
The CURE Hierarchy: SATA
Critical: Emergent, life-threatening situations.
Extras: Delineate between a true ”trend” and an isolated incident
Routine: Routine tasks associated with client care.
Extras: Tasks that are not essential to client care, but promote comfort.
Urgent: client could suffer harm of discomfort if there is a delay
Routine: Recognizing the gradual change or deterioration
6
This uses an ultrasonic device that disintegrates cataracts so they can be aspirated and removed.
Phacoemulsification
astigmatism
extracapsular cataract extraction
Endophthalmitis
7
Deficits that cause Sensorineural Hearing Loss: SATA
Cranial Nerve VIII
Cochlea
Cranial Nerve VII
Brain
8
motor fibers of facial expression and to lacrimal and salivary glands.
Facial
vagus
oculomotor
accessory
9
RN is caring for Pt who had recent CVA.Prior to transferring Pt to bedside commode, what should RN do first?
Request a mechanical lift device
Ask for help with a two-person assist transfer
Medicate the client for pain
Assess the client for functional limitations.
10
What are Factors taht influence Sensory Function?: SATA
Medications
Personality
Gender
Lifestyle
Illness
Stress
11
Two main types of advance directives: SATA
DNR
The “ Living Will” aka Personal directive
Advanced Directions
Durable Power of Attorney for Health Care aka Medical POA
12
Which assessment involves pressure applied to the notch of the eyebone under the inner parts of the eyebrow ~10sec
Supraorbital rub
Supraorbital pressure
Sternal pressure
Sternal rub
13
Touch : receptors found in the skin and allow transcription of our external environment
True
False
14
provides motor fibers to sternocleidomastoid and trapezius muscles.
abducens
facial
trochlear
accessory
15
Conflict between professional duties to a client and obligations to a third party is?
Safeguarding a client’s autonomy
Paternalism
Advocacy
Dual loyalty conflict
16
What is the difference between living will and advance directive?
RN advocating for client in regard to End- of -life care
L.W: Specific documents that shape end-of-life treatment
L.W: Any legal form guiding your future medical care
A.D: Any legal form guiding your future medical care
Not all A.D are living Wills but all L.W are Advanced directives
A.D: Specific documents that shape end-of-life treatment
17
Esotropia and exotropia are both forms of strabismus
False
True
18
What is a psychological safety? SATA
feeling safe to take interpersonal risks, to speak up, to disagree openly
RN having pressure to sugarcoat bad news.
inclusion safety, learner safety, contributor safety, and challenger safety
Bring concerns w/out fear of negative repercussions
19
________ is a disorder in which the eyes cannot be directed to focus on the same object
Strabismus
astigmatism
myopia
hyperopia
20
This assessment tests for nerve system, brain and blood supply
PERRLA
Glasgow Coma Scale
Levels of Consciousness
Dermatome assessment
21
Age-related macular degeneration is a dz dat is slowly progressive, produces changes in ___cells of retina and macula
mast
unpigmented
uveal
pigmented
22
Hordeolum is another term for glaucoma
False
True
23
Inflammation of the edges of the eyelids is blepharitis
False
True
24
Increased intraocular pressure
Amblyopia
Glaucoma
cataracts
muscular degeneration
25
Anisocoria: Eye will not react to light stimulus
False
True
26
Mixed- direct eyeball, muscles of eyelid, controlling lens shape and pupil size.
abducens
vestibulocochlear
Optic
oculomotor
27
Corrected with Lasik, Glasses or Cataracts: SATA
Myopia
Astigmatism (Acuity Disorder)
Presbyopia
Hyperopia
28
The five rights of delegation: SATA
Right patient
Right person
Right circumstance
Right directions and communication
Right task
Right supervision and evaluation
29
Types of Central Stimuli: SATA
Trapezius squeeze
Sternal pressure
Finger nail bed pressure
Supraorbital pressure
30
This stimuli is used to assess GCS: SATA
Supraorbital
Central
Peripheral
Sternal
31
Uveitis is Inflammation of the uveal tract
False
True
32
Spinal Injury Assessment (ASIA): SATA
C. Incomplete:50% of muscle MORE than grade3. Can't raise arms/legs off bed
B. Incomplete: No motor, sensory only
E. Normal: Motor and sensory function are normal
D. Incomplete:50% of muscle MORE than grade3. Can't raise arms/legs off bed
A. Complete: No motor, sensory or sacral sparing
C. Incomplete:50% of muscle LESS than grade3. Can't raise arms/legs off bed
33
Very sleepy, have to shake their shoulder to wake during interaction, may dose off. Need re-wake d/t severe drowsiness
Obtunded
Unresponsive
Stuperous
Lethargic
34
LOC assessment for Stuporous: SATA
Supraorbital pressure
Sternal pressure
Finger nail bed pressure
Trapezius squeeze
35
Delirioum S/S: SATA
Confused
Restlessness
Agitated
Quiet
Impatient
Disoriented
36
RN teaching a new admit Pt who has heart failure about advance directives.Which of the following statements shld RN take
You dont need A.D becos you're competent enough to make decisions yourself
"You shld complete A.D in the event you cant express your own wishes."
You must wait for a period of 6 mnths after ur dx before initiating ur A.D
You will have to speak to an expert who works in social service department
37
Keratitis is an Inflammation of the cornea that is usually unilateral.
True
False
38
Which tests are most helpful in determining a stroke?
Angiography and CT scan
X-ray and Angiography
CT scan and Amputation
X-ray and CT scan
39
Flexion withdrawal from pain (4): SATA
Normal Flexion
Open mouth and stick out tongue
Bend at elbow, move arm to remove yours
Jerk elbow but NO touching the shoulder to remove the pain
40
Eye d/o causes aching in eyes and visual disturbances, such as seeing halos around lights or a loss of peripheral vision
Cataracts
Uveitis
Glaucoma
Macula
41
Which of the following is correct regarding the assessment of a neurological patient?
Glasgow Coma Scale determines if a patient is in a coma (Score below 8)
All answers are correct
Extensor/Decerebrate posture one/both arms are extended; brainstem lesion
Flexor/Decorticate posture is one or both arms are flexed (cortex issue)
42
Barriers to Priority Setting: SATA
Completion of easiest task first
Patient acuity
Nurse-patient relationship
Failure to differentiate between priority and nonpriority problems
Inadequate assessment/evaluation
Acceptance of other's priorities without assessing alternatives
43
decide which needs or prob need immediate attention, and which can be delayed until later cos they are not urgent
Implementation
Assessment
Planning
Prioritization
44
A focused Neuro Assessment involves: SATA
PERRLA
Glasgow Coma Scale
Deep Tendon Reflexs
Dermatomes & ASIA
45
A client is brought to the ED due to anaphylaxis. What is the ED Nurses priority?
Administer medications as ordered.
Protect the patient's airway.
Provide psychosocial support.
Monitor the patient's level of consciousness.
46
GCS: A decrease of 2 points is very significant
True
False
47
Hyperopia occurs when ______ entering the eye comes to a focal point behind the retina
dust
penlight
Light
bacteria
48
Rights to refuse treatment per The Patient Self-Determination Act : SATA
Leaving AMA will not result in a refusal of payment
The refusal should be clearly documented in the medical records
Pt who refuses trtmnt, may forcibly treated ONLY pursuant to a court order
Leaving AMA will result in a refusal of payment
49
WHAT IS THE MOST COMMON TYPE OF STROKE IN THE USA?
Cardiac infarction
TIA
Ischemic
Hemorrhagic
50
Some signs and symptoms of refractive errors are squinting, headaches, and frequent rubbing of eyes
False
True
51
Symptoms of Cataracts: SATA
Clouded
Dim vision in 1 or both eyes
Blurred
Dim vision in 1 eye only
52
Fall asleep multiple times during interactions, wake using verbal & tactile stimulation and can't maintain LOC very long
Lethargic
Obtunded
Unresponsive
Stuporous
53
NIHSS scores: SATA
5-15 Moderate stroke
21-42 Severe stroke
5-15 Minor to Moderate stroke
0 No stroke
0-4 Minor stroke
16-20 Moderate to Severe stroke
54
During phase 1 of stroke management, if there is still danger of hemorrhaging bed rest may be necessary.
False
True
55
Things to remember about GCS: SATA
3 is "comatose" aka Unresponsive
Intubate patient with a GCS of 13
15 patient is fully awake, responsive w/ no probs w/ thinking or memory
8 is "comatose" aka Unresponsive
Lower scores are better
Lowest score is 3, not 0
56
What is the purpose of Dermatome Assessment?
Involves all Cervical levels
C1's dermatome detects Accessory nerve
Detect/diagnose condition or prob affecting spine,spinal cord or its nerves
Each dermatome provides sensory input from a broad area of the skin
57
Name 3 tests used to diagnose refractive errors: SATA
Visual acuity test using Snellen eye chart
Ophthalmoscopy examination
Tonometry
Tests to detect eye muscle function
58
Sensory Overload occurs when a person is unable to process or manage the amount or intensity of sensory stimuli.
False
True
59
RN is planning care for a client who has a deficit w/ cranial nerve II. Which of the following actions should RN take?
Clear objects from the client’s walking area
Evaluate the client’s ability to swallow
Keep the client resting in bed
Ask the client to restate directions
60
Glasgow Coma Scale: SATA
Eye opening 4
Verbal 5
Motor 6
Eye opening 5
Verbal 4
Motor 4
61
BE FAST (Balance, Eyes, Face, Arms, Speech, Time) can be applied to TIA or CVA.
True
False
62
Assessing Motor skill on GCS, Abnormal flexion (3) means? SATA
Decerebrate Posturing
Decorticate Posturing
Cortex is affected
Brain stem is affected
63
Healthcare surrogate: Specific person to make medical decisions if a person is unable to do so. ie Withdraw/ refuse care
False
True
64
another term for double vision is diplopia
False
True
65
Healthcare provider makes decisions for a client without the explicit of the client.
Nurse’s responsibility
Paternalism
Dual loyalty conflicts
Disregard to Informed consent
66
Triad symptoms of Meniere's Disease?: SATA
Vertigo
Tinnitus
N/V
Hearing Loss
67
What are Sensory Aids for Hearing Deficits: SATA
Amplified telephones
Sign Language
Smoke Detectors
Flashing alarm
Lip freading
Clocks
68
Put the PRO in PROfessional: SATA
Opportunities
Planning
Pride
Respect
69
Name 3 common symptoms of a corneal abrasion: SATA
tearing
redness
pain
tingling
70
NIHSS: The lower the score, the less deficits a client has
False
True
71
Decrease or lack of meaningfdul stimuli is called Sensory Deprevation
False
True
72
A cataract is the opacity of the crystalline lens or ______ ______.
Extracapsular cataracts
middle layer aka uvea
surrounding membrane
external layer aka sclera
73
When prioritizing care also consider: SATA
Chronicity of disease
Pathophysiology
Ethnicity
Surgical interventions
Age
Days post op
74
Repetitive, involuntary, and rapid movement of the eye
astigmatism
nystagmus
presbyopia
Strabismus
75
PERRLA: Assessing accommodation results in pupil constriction and eye converge
True
False
76
A licensed nurse has ultimate responsibility and accountability for the management and provision of patient care
False
True
77
You have 4 clients who are post op or pre op for surgery. Which assessment findings requires further nursing action?
Orange colored urine in a pt taking Pyridium and post op day 3 from TURP.
Shoulder pain in a pt who's post op day 1 from a lap cholecystectomy.
Pain rating that has decreased from a 10 to 0 in a pt awaiting an appy
No stool excretion in a client who is post op day 2 from a colostomy
78
The yellow disc on the retina directly behind the lens.
macula
Uveitis
presbyopia
hyperopia
79
_____ is a disorder in which dark green eye glasses are typically worn.
macula
hyperopia
Uveitis
astigmatism
80
Only awake to vigorous tactile stimulations. May need to use painful stimuli to wake client.
Unresponsive
Stuporous
Lethargic
Obtunded
81
Name the common refractive errors: SATA
hyperopia
myopia
astigmatism
presbyopia
82
Name the treatments for refractive errors: SATA
Photorefractive keratectomy
Astigmatic keratectomy
Intrasomal corneal rings
Laser eye surgery
83
As the RN, you are making the client assignments for the next shift. Which client would you assign to the LPN?
85 yr female w/Alzheimer disease who has colostomy and scheduled tube feed
68 yr old male pt experiencing A-fib and is receiving a Diltiazem drip.
45 yr old male pt who is ordered to receive 2 units of pack red blood cells
A 25 year old female client newly admitted with diabetic ketoacidosis.
84
How do nurses promote human flourishing? SATA
Teaching client not to engage in holistic care d/t EBP
Quality
Disregarding the cognitive and physical limitations of the client
Safety
85
Not all tasks can be delegated. Remember - PACET: SATA
Assessment
Teaching
Planning
Evaluation
Collaboration
Prioritizing
86
After a change of shift, you are assigned to care for the following patients. Which patient should you assess first?
50 yr old with asthma who complains of SOB after using a bronchodilator.
55 yr w/COPD and a pulse ox reading 65% from the previous shift of 90% sat
70 yr old w/pneumonia who needs to be started on IV antibiotics
60 yr pt on a vent whose sterile sputum specimen must be sent to the lab
87
Inflammation of the conjunctiva, also known as conjunctivitis, is most commonly called "pink eye".
True
False
88
Sensory impulses from skin of face, anterior scalp; mucosa of mouth to nose, chewing muscles.
trigeminal
optic
trochlear
hypoglossal
89
Age-related macular degeneration can cause blindness
False
True
90
These aid in sensory and visual deficit clients: SATA
Limiting bright light
Adequate lighting
Correct prescription for glasses
Color coding
Medium Text
Large Text
91
___causes an individual to see cobwebs, floating spots, flashes of light, or a sensation of shade coming across the eye.
Retinal Detachment
nystagmus
Glaucoma
blepharitis
92
Minimize unnecessary noise,distractions,uninterrupted periods of rest/sleep is RN intervention:prevent Sensory overload
False
True
93
Which of the following is a common treatment for strokes?
Antihypertensive and Antipyretics
All of the above
Alteplase/TPA(Unless there is a history of bleeding/intracerebral bleeding)
Aneurysm coiling/clipping; Thrombectomy
94
A pt admitted w/COPD. Which intervention for airway management should you delegate to a nursing assistant?
Instructing the patient to cough effectively.
Assisting the patient to sit up on the side of the bed.
Auscultation of breath sounds every 4 hours.
Teaching the patient to use incentive spirometry.
95
Obstruction of sound wave transmission
Conductive hearing loss
components of sensory reception
delirium
Sensory deprevation
96
RN planning care for pt w/AIDS admitted to Med/Surg unit w/Pneumocystis pneumonia (PCP).Which RN dx is highest priority
Activity Intolerance.
Imbalanced Nutrition: Less than Body Requirements
Ineffective Airway clearance
Impaired Oral Mucous Membranes
97
assigning tasks to another person who is
competent
to perform a
selected task
in a
selected situation
Planning
Delegation
Implementation
Diagnosis
98
What are the three things an RN Cannot delegate? SATA
clinical reasoning
nursing judgment
ADLs
critical decision making
99
Abnormal extension (2) on GCS means: SATA
Decerebrate Posturing
Decorticate
Cortex is affected
Brain stem is affected
