Nokea
A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, 'How does glaucoma damage my eyesight?' The nurse's reply should be based on the knowledge that COAG:
- A. Results from chronic eye inflammation.
- B. Causes increased intraocular pressure.
- C. Leads to detachment of the retina.
- D. Is caused by decreased blood flow to the retina.
Correct Answer: B
Rationale: Chronic open-angle glaucoma causes increased intraocular pressure, which damages the optic nerve over time, leading to vision loss.
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The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or dehydration, requiring urgent attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical symptoms.
A client on hemodialysis reports muscle cramps. The nurse should:
- A. Increase dialysate flow.
- B. Check electrolyte levels.
- C. Administer a diuretic.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Muscle cramps may indicate electrolyte imbalances, requiring lab assessment.
The development of a culturally sensitive health education program for the socioeconomically disadvantaged requires the nurse to:
- A. Locate the program at an existing government facility.
- B. Integrate folk beliefs and traditions into the content.
- C. Prepare materials in the primary language of the program sponsor.
- D. Exclude community leaders from initial planning efforts.
Correct Answer: B
Rationale: Integrating folk beliefs and traditions ensures the program is culturally relevant and increases acceptance and effectiveness among socioeconomically disadvantaged populations.
A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?
- A. Lean beef.
- B. Air-popped popcorn.
- C. Hot chocolate.
- D. Raw vegetables.
Correct Answer: C
Rationale: Hot chocolate contains caffeine and fat, both of which can relax the lower esophageal sphincter and worsen GERD-related heartburn. The other options are less likely to trigger symptoms.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
- A. Teaching how to prevent hip flexion.
- B. Demonstrating coughing and deep-breathing techniques.
- C. Showing the client what an actual hip prosthesis looks like.
- D. Assessing the client's fears about the procedure.
Correct Answer: A
Rationale: Preventing hip flexion is critical to avoid dislocation post-surgery.