Nokea
A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate?
- A. Correction with laser surgery
- B. Eye drops in the affected eye
- C. Measurement of intraocular pressure
- D. Patching of the unaffected eye
Correct Answer: D
Rationale: Patching the unaffected eye strengthens the weaker eye in strabismus by forcing its use, a common non-surgical treatment in children. Laser surgery is not typically used, eye drops are irrelevant, and intraocular pressure measurement is for glaucoma, not strabismus.
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The nurse is caring for a client diagnosed with generalized anxiety disorder. What behavior demonstrates that the client is building resilience toward improving anxiety symptoms?
- A. Avoids anxiety-producing situations
- B. Identifies anxiety-reducing triggers
- C. Practices stress-reduction techniques daily
- D. Relies on medication to manage symptoms
Correct Answer: C
Rationale: Practicing stress-reduction techniques daily, such as mindfulness or deep breathing, actively builds resilience by equipping the client with tools to manage anxiety symptoms effectively. Avoiding situations may reinforce anxiety, identifying triggers is helpful but less proactive, and relying solely on medication does not foster long-term resilience.
The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. excessive thirst
- B. increased urine output
- C. increased serum osmolality
- D. decreased serum sodium level
- E. increased urine specific gravity
Correct Answer: A,B,C
Rationale: Diabetes insipidus results from antidiuretic hormone deficiency, causing excessive thirst, increased dilute urine output, and increased serum osmolality due to water loss. Serum sodium may increase, not decrease, and urine specific gravity is low due to dilute urine.
A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate’s vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next?
- A. Call the health care provider immediately
- B. Document the finding
- C. Place the neonate in a knee-chest position
- D. Provide oxygen to the neonate
Correct Answer: B
Rationale: Documenting the murmur is appropriate as genetic screening and an echocardiogram are already scheduled, indicating the provider is aware. Calling the provider is unnecessary, knee-chest position is for specific heart defects, and oxygen is not indicated without respiratory distress.
The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply.
- A. Keeps hearing aids clean by rinsing them with water
- B. Lowers television volume when talking with nurse
- C. Places hearing aids on food tray when not in use
- D. Turns volume completely down prior to insertion of aid into the ear
- E. Verifies that battery compartment is closed before insertion
Correct Answer: B,D,E
Rationale: Lowering TV volume indicates effective hearing aid use, turning volume down prevents feedback, and verifying the battery compartment ensures functionality. Rinsing with water damages hearing aids, and placing them on a food tray risks contamination or loss.
The nurse is assisting in developing the plan of care for a client diagnosed with anorexia nervosa who is being admitted after unsuccessful outpatient treatment. The nurse understands that which client outcome is the priority?
- A. Acknowledges poor interpersonal skills
- B. Identifies new coping mechanisms
- C. Increases caloric intake to gain weight
- D. Verbalizes sources of conflict and anger
Correct Answer: C
Rationale: In anorexia nervosa, severe malnutrition poses immediate health risks, making increased caloric intake and weight gain the priority to stabilize physical health. Addressing interpersonal skills, coping mechanisms, or emotional conflicts is secondary until nutritional status improves.