Nokea
Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct Answer: D
Rationale: Diabetic retinopathy, a common complication, requires regular eye examinations to detect and prevent vision loss.
You may also like to solve these questions
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (C) and pupil reaction (D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
Which of the following should the nurse provide as part of the information to prepare the client for tonometry?
- A. Oral pain medication will be given before the procedure.
- B. It is a painless procedure with no adverse effects.
- C. Blurred or double vision may occur after the procedure.
- D. Medication will be given to dilate the pupils before the procedure.
Correct Answer: B
Rationale: Tonometry measures intraocular pressure and is typically painless with no adverse effects, requiring no pupil dilation or pain medication.
During rescue breathing in cardiopulmonary resuscitation (CPR), the victim will exhale by:
- A. Normal relaxation of the chest.
- B. Gentle pressure of the rescuer's hand on the upper chest.
- C. The pressure of cardiac compressions.
- D. Turning the head to the side.
Correct Answer: A
Rationale: Exhalation during CPR occurs naturally due to chest relaxation after the rescuer delivers a breath, allowing air to exit the lungs.
The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
- A. Cardiac arrhythmias.
- B. Liver failure.
- C. Renal failure.
- D. Hemorrhage.
Correct Answer: D
Rationale: AML causes pancytopenia, including thrombocytopenia, increasing the risk of hemorrhage. Preventing bleeding is a primary nursing goal through measures like avoiding invasive procedures and monitoring for bleeding signs. Arrhythmias, liver, and renal failure are less immediate concerns.
A nurse is treating a client who came to the emergency department after getting bit by a snake on their arm. After confirming the resuscitation equipment is at the bedside, which of the following actions by the nurse would be a priority?
- A. Contact Poison Control for guidance on an antivenom.
- B. Ensure the client's peripheral intravenous (IV) lines are patent.
- C. Apply a tourniquet above the snake bitten area on the arm.
- D. Assess for rash, fever, chills, nausea, vomiting, and joint pain.
Correct Answer: B
Rationale: Ensuring patent IV lines is the priority to enable rapid antivenom or fluid administration, critical for snakebite management. Contacting Poison Control (A) is secondary, tourniquets (C) are harmful, and symptom assessment (D) is important but not the immediate priority.