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A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff 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: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet.
Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.
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Clinical manifestations of Huntington’s disease include:
- A. Abnormal involuntary movements (chorea)
- B. Intellectual decline
- C. Emotional disturbances
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is a hallmark feature of Huntington's disease, caused by damage to the basal ganglia. Intellectual decline includes cognitive impairments such as memory loss and executive dysfunction. Emotional disturbances involve mood swings, irritability, and apathy. Therefore, all three manifestations are commonly seen in individuals with Huntington's disease, making D the correct choice. Choices A, B, and C are incorrect individually because they do not encompass all the key clinical features of Huntington's disease.
A client’s blood glucose levels remain elevated despite adherence to the prescribed treatment plan. What is the nurse’s best action?
- A. Reassess the client’s diet, medication, and lifestyle habits.
- B. Increase the client’s medication dosage.
- C. Document the elevated levels and continue with the current plan.
- D. Notify the client’s family about the lack of progress.
Correct Answer: A
Rationale: The correct answer is A because reassessing the client's diet, medication, and lifestyle habits allows the nurse to identify any factors contributing to the elevated blood glucose levels. By identifying possible issues, the nurse can make necessary adjustments to the treatment plan to better manage the client's condition. Increasing medication dosage without understanding the root cause may lead to adverse effects. Simply documenting the elevated levels without taking proactive measures does not address the problem. Notifying the client's family is not the nurse's first action; the focus should be on assessing and addressing the client's needs.
Nurse Raymond is handling a group of student nurses and he is teaching them about fluids and electrolytes. He is correct when he says that a substance moves from an area of higher concentration, this is:
- A. osmosis
- B. filtration
- C. diffusion
- D. active transport
Correct Answer: C
Rationale: Correct Answer: C - Diffusion
Rationale: Diffusion is the movement of a substance from an area of higher concentration to an area of lower concentration. This process occurs naturally to achieve equilibrium. In the context of fluids and electrolytes, this movement helps maintain balance within the body. Unlike osmosis, which involves the movement of water molecules across a semi-permeable membrane, diffusion applies to the movement of all types of substances. Filtration involves the movement of substances through a barrier under pressure, and active transport requires energy to move substances against a concentration gradient. Therefore, the correct answer is diffusion as it aligns with the principle of movement from high to low concentration for achieving equilibrium.
The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
- A. Administer the acetaminophen.
- B. Notify the health care provider to obtain a verbal order.
- C. Direct the nursing assistive personnel to give the acetaminophen.
- D. Perform a pain assessment only after administering the acetaminophen.
Correct Answer: A
Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows:
1. The patient has a standing order for acetaminjson for headache relief.
2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours.
3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs.
Summary:
- Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order.
- Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision.
- Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
- A. Scalp
- B. Chest
- C. Axillae
- D. Conjunctivae
Correct Answer: D
Rationale: The correct answer is D: Conjunctivae. Pallor is best assessed in the conjunctivae due to the transparent nature of the tissue, allowing for easy observation of paleness. The conjunctivae are the mucous membranes lining the inner surface of the eyelids and covering the sclera. Anemia can cause decreased hemoglobin levels, resulting in paleness of the mucous membranes. Assessing the scalp (A), chest (B), or axillae (C) may not provide a clear indication of pallor related to anemia. The conjunctivae offer a direct and reliable site to assess for pallor in patients with anemia.