Nokea
Before the examination can be completed, which type of eye medication would the nurse instill in the client's eye to dilate the pupil and temporarily paralyze the ciliary muscle?
- A. Pilocarpine (Pilocar)
- B. Dipivefrin (Propine)
- C. Gentamicin (Genoptic)
- D. Cyclopentolate solution (Cyclogyl)
Correct Answer: D
Rationale: Cyclopentolate is a cycloplegic agent that dilates the pupil and paralyzes the ciliary muscle for retinoscopy.
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The home health nurse is visiting an elderly client who shows the nurse an area of rough skin with a greasy feel and multiple papules. Which information should the nurse provide the client?
- A. Contact the health-care provider immediately for an appointment.
- B. Tell the client this is a normal aging change and no action should be taken.
- C. Tell the client to discuss this with the HCP at the next appointment.
- D. Have the client buy a wart remover kit at the store.
Correct Answer: C
Rationale: Rough, greasy papules may indicate seborrheic keratosis, requiring HCP evaluation at the next visit. Immediate visits, dismissing as normal, or OTC wart removers are inappropriate.
The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel?
- A. Measure and document the client’s skin lesions.
- B. Apply the antihistamine cream to the lesions.
- C. Set up the isolation equipment for the client.
- D. Determine if the client has prepared an advance directive.
Correct Answer: C
Rationale: Setting up isolation equipment is within UAP scope. Measuring lesions, applying medication, and assessing advance directives require nursing judgment.
The nurse is most accurate in stating that the cause of Meniere's disease is unknown but that the symptoms are related to which disorder?
- A. A non-suppurative inflammation
- B. A disturbance in the balance of inner ear fluid
- C. An infection in the middle ear
- D. An autoimmune response in the cochlea
Correct Answer: B
Rationale: Meniere's symptoms stem from inner ear fluid imbalance.
The client sustained partial- and full-thickness burns to the anterior left and right arms, anterior chest and abdominal area, and anterior left leg. Using the Rule of Nines, what is the estimated extent of this injury that the nurse should document? % (Record your answer as a whole number.)
- A. 36
Correct Answer: A
Rationale: According to the Rule of Nines, this client sustained injuries on about 36% of the body surface: right arm is 4.5%; left arm is 4.5%; left leg is 9%; anterior chest and abdomen are 18%.
The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement?
- A. Instruct the football players to wear tight, snug-fitting jock straps.
- B. Explain the importance of wearing white socks.
- C. Teach the football players to not share brushes or combs.
- D. Discuss the need to dry the groin area thoroughly after bathing.
Correct Answer: D
Rationale: Thorough drying prevents moisture buildup, reducing tinea cruris risk. Tight jock straps trap moisture, socks are irrelevant, and brushes are unrelated.