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When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of 'visual sensory/perceptual alterations.' This problem is based on which etiology?
- A. Blurred distance vision
- B. Limited eye movement
- C. Decreased peripheral vision
- D. Photosensitivity
Correct Answer: C
Rationale: The correct answer is 'C: Decreased peripheral vision.' Open-angle glaucoma leads to a gradual loss of peripheral vision due to damage to the optic nerve. This loss of peripheral vision is a hallmark sign of the condition and a primary reason for the visual sensory/perceptual alterations experienced by the client. Blurred distance vision (choice A) may occur but is not the priority nursing problem. Limited eye movement (choice B) and photosensitivity (choice D) are not typically associated with the sensory/perceptual alterations seen in open-angle glaucoma.
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In a patient with liver cirrhosis, which of the following lab results would be expected?
- A. Increased bilirubin levels.
- B. Decreased albumin levels.
- C. Increased liver enzymes.
- D. Decreased platelet count.
Correct Answer: A
Rationale: In a patient with liver cirrhosis, increased bilirubin levels would be expected. Liver cirrhosis leads to impaired liver function, causing a decrease in the liver's ability to process bilirubin, leading to its accumulation in the blood. This results in elevated bilirubin levels. Decreased albumin levels (choice B) may occur in liver cirrhosis due to impaired liver synthesis of proteins, but it is not as specific as increased bilirubin levels. Increased liver enzymes (choice C) can be seen in liver damage but are not as characteristic as elevated bilirubin levels. Decreased platelet count (choice D) can occur in liver cirrhosis due to hypersplenism, but it is not as specific as increased bilirubin levels in this context.
In a patient with pneumonia, what is the primary goal of treatment?
- A. Reducing inflammation.
- B. Eliminating the infection.
- C. Reducing pain.
- D. Preventing complications.
Correct Answer: B
Rationale: The primary goal of treating pneumonia is to eliminate the infection. Antibiotics are commonly used to target the specific pathogen causing pneumonia. While reducing inflammation and preventing complications are important aspects of treatment, the key focus initially is on eradicating the infectious agent to improve the patient's condition and prevent further spread of the infection.
A client with chronic heart failure is being taught by a nurse about the importance of daily weights. Which of the following instructions should the nurse include?
- A. Weigh yourself at the same time every day.
- B. Use the same scale for weighing each time.
- C. Record your weight in a journal or log.
- D. Report any weight gain of more than 2 to 3 pounds in a day.
Correct Answer: D
Rationale: The correct instruction for a client with chronic heart failure is to report any weight gain of more than 2 to 3 pounds in a day. This weight gain may indicate fluid retention, which is a critical sign of worsening heart failure. Weighing at the same time every day and using the same scale for consistency are good practices, but the crucial action is to promptly report significant weight gain, as stated in option D. Recording the weight in a journal or log can be helpful for tracking trends, but immediate reporting of weight gain is essential for timely intervention in heart failure management. Therefore, option D is the most appropriate instruction for this client.
The healthcare provider is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes?
- A. Aspirin
- B. Steroids
- C. Sulfonylureas
- D. Angiotensin-converting enzyme (ACE) inhibitors
Correct Answer: B
Rationale: The correct answer is B: Steroids. Steroids can induce hyperglycemia, complicating diabetes management by raising blood sugar levels. Aspirin is not typically associated with causing complications in diabetic clients. Sulfonylureas are oral antidiabetic medications that can lower blood sugar levels and are commonly used in diabetes management, making them beneficial rather than harmful. Angiotensin-converting enzyme (ACE) inhibitors are medications often prescribed to manage hypertension in diabetic clients and do not typically interfere with diabetes treatment plans.
The healthcare provider is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL).
- C. An online nursing textbook.
- D. The policy and procedure manual at the healthcare agency.
Correct Answer: A
Rationale: The Cochrane Library provides systematic reviews of primary research in healthcare, making it a reliable resource for evidence-based practice. Choice B, a literature search in a database like CINAHL, may also be useful but does not guarantee the same level of systematic review and reliability as the Cochrane Library. Choice C, an online nursing textbook, may offer information but might not provide the most current or evidence-based practices. Choice D, the policy and procedure manual at the healthcare agency, is unlikely to offer the comprehensive evidence-based information needed for developing standards of care.