A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse recognizes these manifestations are likely related to a condition with which of the following characteristics?

Isolated

permanent

Reversible

Unique

Answer and Explanation

The Correct Answer is C

A. Isolated: This term refers to something that is separate or distinct. Confusion and agitation in a client are not typically isolated but can be part of a broader clinical picture.

B. Permanent: These manifestations are not typically permanent and can often be reversed with appropriate interventions.

C. Reversible: Confusion and agitation in a client are often reversible and can be due to various factors such as medications, infections, metabolic disturbances, or other medical conditions. Identifying and addressing the underlying cause can often restore the client to their baseline mental status.

D. Unique: While every individual's presentation may have unique aspects, confusion and agitation are not considered unique manifestations in the context of acute changes in mental status. They are common symptoms that can occur due to a variety of reasons and are not exclusive to any particular condition.

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Correct Answer is B

Explanation

A. Myopia: Myopia refers to nearsightedness, which is caused by refractive errors in the eye and is not associated with Meniere's disease. Myopia results in difficulty seeing distant objects clearly.

B. Vertigo: Vertigo is a hallmark symptom of Meniere's disease and is caused by an excessive accumulation of endolymph fluid in the inner ear. Vertigo presents as a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance.

C. Photophobia: Photophobia refers to sensitivity to light, which can be associated with various eye conditions but is not a typical manifestation of Meniere's disease. Photophobia may occur in conditions such as migraine headaches or certain eye infections.

D. Presbycusis: Presbycusis refers to age-related hearing loss, which typically occurs gradually over time and is not directly associated with Meniere's disease. Meniere's disease is characterized by sudden episodes of vertigo, hearing loss, tinnitus, and a sensation of fullness or pressure in the ear.

A. "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor." B. "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina." C. "Vision changes occur when the cloudy lens alters the passage of light through the eye." D. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye."

Correct Answer is C

Explanation

A) "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor." This statement describes a mechanism associated with glaucoma, not cataracts. In cataracts, vision changes occur due to the opacity or cloudiness of the lens, not changes in intraocular pressure.

B) "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina." This statement describes a mechanism associated with retinal diseases like diabetic retinopathy, not cataracts. In cataracts, the lens becomes cloudy, affecting the passage of light through the eye.

C) "Vision changes occur when the cloudy lens alters the passage of light through the eye." This statement is correct. Cataracts cause the lens of the eye to become cloudy, which interferes with the passage of light through the eye. This results in vision changes such as blurred vision, glare, and difficulty seeing in low light conditions.

D) "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." This statement describes a mechanism associated with retinal detachment, not cataracts. In cataracts, the lens becomes opaque, but the retinal tissue remains intact.

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A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse recognizes these manifestations are likely related to a condition with which of the following characteristics?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Meniere’s disease. The nurse identifies that which of the following manifestations is caused by an excessive accumulation of endolymph fluid?

Correct Answer is B

Explanation

A nurse is providing teaching to a group of clients about the changes that occur when clients experience cataracts. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply.)

A nurse is admitting a client who has suspected retinal detachment. Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)

A nurse is caring for a group of clients. After receiving bedside report, the nurse determines which of the following clients to be at greatest risk for developing delirium?

A nurse is reviewing laboratory results for a client who has pericarditis. Which of the following blood test results should the nurse anticipate? (Select All that Apply.)

A nurse is planning care for a client who has worsening heart failure and is experiencing arrhythmias. Which of the following procedures should the nurse anticipate the client will require to regulate the rhythm?

A nurse is reinforcing teaching to a group of nursing students about possible psychosocial changes a client might have after sustaining a neurologic injury such as increased intracranial pressure. Which of the following psychosocial changes should the nurse include in the teaching?

A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?

A nurse is caring for a client in the intensive care unit. Which of the following laboratory values could contribute to an episode of delirium?