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A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
- E. Visual acuity
Correct Answer: B,C,D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are B, C, D, and E. Pupil clarity is crucial for detecting any visual impairments that may increase fall risk. The appearance of bulbar conjunctivae can indicate underlying eye conditions affecting vision and balance. Assessing visual fields helps identify potential blind spots that may contribute to falls. Visual acuity is essential for clear vision and spatial awareness, both critical for preventing falls. Choices A and F have no direct relevance to assessing fall risk in older adults, making them incorrect options.
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A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn’s disease.
- A. Fever
- B. Steatorrhea
- C. Anemia
- D. Weight loss
- E. Diarrhea
Correct Answer: A, B, C, D
Rationale: To determine which assessment findings are consistent with ulcerative colitis, diverticulitis, or Crohn's disease, we need to analyze the characteristics of each condition.
1. Fever : This finding can be seen in all three conditions, but it is more commonly associated with Crohn's disease due to the inflammatory nature of the disease.
2. Steatorrhea (B): This is a common symptom of Crohn's disease due to malabsorption issues, making it a key indicator for this condition.
3. Anemia (C): Anemia is a common complication of inflammatory bowel diseases like ulcerative colitis and Crohn's disease, often related to chronic inflammation and blood loss.
4. Weight loss (D): This is a common feature of all three conditions due to malabsorption, decreased appetite, and chronic inflammation.
Therefore, the correct answer is A, B, C, D as these findings are consistent with all three conditions. Diarrhea (E
A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should turn on the ceiling fan to block out unwanted noise.
- B. I will limit my daily nap to 45 minutes.
- C. I will drink a cup of green tea at bedtime to help me sleep.
- D. I should get out of bed if I cannot fall asleep within an hour of lying down.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Limiting naps to 45 minutes can help improve nighttime sleep in individuals with insomnia by reducing excessive daytime sleepiness and ensuring better sleep quality at night. Longer naps can disrupt the body's natural sleep-wake cycle and make it harder to fall asleep at night. This statement shows an understanding of the importance of sleep hygiene practices for managing insomnia.
Summary:
A: Turning on the ceiling fan may help create white noise, but it does not address the underlying issue of improving sleep quality.
C: Drinking green tea before bedtime can actually worsen insomnia due to its caffeine content.
D: Getting out of bed if unable to sleep within an hour can disrupt the sleep routine and make it harder to fall asleep.
Therefore, the correct choice is B as it directly addresses the management of insomnia by improving sleep habits.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A because when setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come in contact with the solution, remains sterile. Placing the cap sterile-side up prevents contamination and maintains the integrity of the sterile field.
Choices B, C, and D are incorrect. Placing sterile gauze over spilled solution does not address the primary concern of maintaining sterility. Holding the bottle in the center of the sterile field or with the label facing away from the palm does not directly impact the sterility of the solution. Therefore, they are not the best actions to take when pouring the sterile solution during wound irrigation.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct action the nurse should take first is to remove the device from the room (Choice C). This is crucial because a frayed electrical cord poses a significant safety risk, potentially leading to electric shock or fire hazard. By removing the device from the room, the nurse ensures that the client and others are not exposed to the danger posed by the damaged cord. Initiating a requisition for a replacement device (Choice A) can be done after ensuring immediate safety. Reporting the defect to equipment maintenance staff (Choice B) is important, but it is secondary to removing the device from the room. Ensuring the device inspection sticker is current (Choice D) is not the priority when there is a clear safety issue present.