Nokea
A client has undergone the Snellen eye chart and has 20/40 vision. Which of the following is true for this client?
- A. The client sees letters at 20 feet that others can read at 40 feet
- B. The client sees letters at 40 feet that others can read at 20 feet
- C. The client sees colors at 20 feet that others can see at 40 feet
- D. The client sees colors at 40 feet that others can see at 20 feet
Correct Answer: A
Rationale: 20/40 vision means the client can see at 20 feet what a person with normal vision can see at 40 feet.
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In planning Mrs. Filbert's care during an acute attack of Meniere disease, it would be most important to
- A. encourage her to discuss her feelings about her illness
- B. keep her siderails up and provide assistance when she is permitted out of bed
- C. instruct her about prescribed dietary modifications
- D. encourage her to walk around her room so that her joints will not get stiff
Correct Answer: C
Rationale: Dietary changes, such as reducing salt intake, play a key role in managing Meniere disease by helping control fluid balance in the inner ear.
Expected age-related changes of the pulmonary system include:
- A. Significant airway obstruction
- B. Shortness of breath
- C. Development of emphysema
- D. A modest,gradual decline in pulmonary function
Correct Answer: D
Rationale: While lung capacity decreases with age, it typically results in a gradual decline rather than significant obstruction or diseases like emphysema unless other factors (e.g., smoking) are present.
In monitoring patients who are at risk for spinal cord compression related to tumor growth, what is the most likely early manifestation?
- A. Sudden-onset back pain.
- B. Motor loss.
- C. Constipation.
- D. Urinary hesitancy.
Correct Answer: A
Rationale: Sudden-onset back pain is often the first symptom of spinal cord compression and warrants urgent evaluation.
Your patient is often fatigued as a result of having anemia. She asks you why she is fatigued. You respond by saying
- A. Destruction (hemolysis) of the red blood cells.
- B. Paleness (pallor) of the skin.
- C. Lack of nutritional intake of essential nutrients, such as iron or B12.
- D. Decreased oxygen-carrying capability of the blood.
Correct Answer: D
Rationale: Anemia reduces the blood's ability to carry oxygen, leading to fatigue.
Which task is appropriate to delegate to the nursing assistant?
- A. Chest compressions
- B. Bag-valve mask ventilation
- C. Assisting with oral intubation
- D. Placing the defibrillator pads
Correct Answer: A
Rationale: Chest compressions are a physical task that can be delegated to a nursing assistant under supervision.