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Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution?
- A. Wear a patch over one eye.
- B. Place personal items on the sighted side.
- C. Lie in bed with the unaffected side toward the door.
- D. Turn the head from side to side when walking.
Correct Answer: B
Rationale: Placing personal items on the sighted side enhances safety by ensuring the client can see and access items easily, reducing the risk of falls or accidents.
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The nurse is providing follow-up care to a client with tuberculosis who does not regularly take his medication. Which nursing action would be most appropriate for this client?
- A. Ask the client's spouse to supervise the daily administration of the medications.
- B. Visit the client weekly to ask him whether he is taking his medications regularly.
- C. Notify the physician of the client's noncompliance and request a different prescription.
- D. Remind the client that tuberculosis can be fatal if it is not treated promptly.
Correct Answer: A
Rationale: Having a spouse supervise medication administration ensures adherence, critical for tuberculosis treatment. Weekly visits are insufficient. Changing prescriptions doesn't address noncompliance. Fear-based reminders are less effective than direct support.
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:
- A. Contact the surgeon to request an order for a narcotic for the pain.
- B. Maintain the client in a recumbent position.
- C. Place the client on nothing-by-mouth (NPO) status.
- D. Apply heat to the abdomen in the area of the pain.
Correct Answer: C
Rationale: The client with acute appendicitis should be placed on NPO status in preparation for surgery to prevent aspiration risk. Narcotics may mask symptoms, a recumbent position is not specific, and heat could worsen inflammation. CN: Physiological adaptation; CL: Synthesize
The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy?
- A. Acromegaly.
- B. Cushing's disease.
- C. Diabetes mellitus.
- D. Hypopituitarism.
Correct Answer: D
Rationale: Hypophysectomy can impair pituitary function, leading to hypopituitarism, with symptoms like fatigue, weakness, and hormonal deficiencies.
A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care?
- A. Relieving pain.
- B. Preserving joint function.
- C. Maintaining usual ways of accomplishing tasks.
- D. Preventing joint deformity.
Correct Answer: C
Rationale: During the acute phase, relieving pain, preserving joint function, and preventing deformity are critical to manage inflammation and prevent long-term damage. Maintaining usual ways of accomplishing tasks is less urgent.
Which of the following should be included in the teaching plan for a cancer client who is experiencing thrombocytopenia? Select all that apply.
- A. Use an electric razor.
- B. Use a soft-bristle toothbrush.
- C. Avoid frequent flossing for oral care.
- D. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control.
- E. Monitor temperature daily.
- F. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional.
Correct Answer: A,B,C,F
Rationale: Thrombocytopenia increases bleeding risk, so using an electric razor (A), soft-bristle toothbrush (B), avoiding flossing (C), and reporting bleeding (F) are critical to prevent and monitor bleeding complications. NSAIDs (D) are contraindicated, and temperature monitoring (E) is unrelated to thrombocytopenia.