Nokea
A nurse is providing teaching to a group of clients about the changes that occur in the eye when clients experience retinal detachment. Which of the following statements should the nurse include in the teaching?
- A. Vision changes occur suddenly due to complete obstruction of aqueous humor outflow
- B. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye
- C. Vision changes occur when the retina begins to breakdown and collect bits of debris
- D. Vision changes occur when the cloudy lens alters the passage of light through the eye
Correct Answer: B
Rationale: Retinal detachment occurs when the retina separates from its supporting tissues and blood vessels, leading to vision loss. Other options describe different eye conditions like glaucoma, macular degeneration, or cataracts.
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A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
- A. To place my leg under a heat lamp every 3 hours
- B. Keep a heating pad on the calf of my right leg when I am lying down.
- C. wrap a warm, wet towel around my right calf every 4 hours.
- D. will sit on the side of the tub and soak my right leg two times every day.
Correct Answer: C
Rationale: A warm, wet towel provides moist heat, promoting blood flow and healing in cellulitis without risking burns or uneven heating from other methods.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
- A. "I need something for the pain in my eye. I can't stand it."
- B. "It's hard to see with a patch on one eye. I'm afraid of falling"
- C. "My eye really itches, but I'm trying not to rub it."
- D. "The bright light in this room is really bothering me."
Correct Answer: A
Rationale: Severe pain after cataract surgery is unusual and could indicate complications like increased intraocular pressure or infection, requiring immediate reporting. Other comments reflect common post-surgical experiences.
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Slurred speech
- B. Confusion
- C. Pain
- D. Fatigue
Correct Answer: D
Rationale: Fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen-carrying capacity of the blood, leading to tiredness and lack of energy. Slurred speech, confusion, and pain are not typical symptoms unless associated with severe or advanced stages.
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.