A nurse is teaching a client who has fibromyalgia about strategies that might
help reduce her symptoms. What should the nurse include in the client
education?
- A. Avoid exercise during flare-ups
- B. Do high impact exercises like running
- C. Establish a regular sleep pattern
- D. Increase calcium and caffeine intake
Correct Answer: C
Rationale:
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A nurse is caring for an immobile client. What is the priority assessment in this
client?
- A. Auscultation of lung sounds
- B. Assessment of skin turgor
- C. Auscultation of bowel sounds
- D. Assessment for the presence of peripheral edema
Correct Answer: A
Rationale:
A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?
- A. Once retinal detachment occurs, it does not return to its normal state
- B. Once the tissue has necrosed from high-pressure, it does not regenerate
- C. Glaucoma always leads to permanent blindness
- D. Once bacterial infection has caused damage, the tissue does not regenerate
Correct Answer: B
Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client
indicates need for further teaching about preventing dry skin?
- A. I will drink at least 3000 mL of water daily."?
- B. . 'I will shower every day in hot water."?
- C. I will avoid tights belts."?
- D. I will use a humidifier during the winter months."?
Correct Answer: B
Rationale:
A client with lupus experience Raynaud's phenomenon. What should the nurse
include when providing client education about this?
- A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
- B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
- C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
- D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'
Correct Answer: A
Rationale:
A client is post-operative day 1 and reports a sudden increase in blood-tinged
liquid draining from his incision after feeling a popping sensation. What is the
nurse's next action?
- A. Send the client back to surgery
- B. Assess the wound for signs of dehiscence
- C. Call the provider immediately
- D. Prepare to culture the wound
Correct Answer: B
Rationale: