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Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Orient the client to the environment
- B. Call for an ophthalmological exam
- C. Provide an eye patch
- D. Avoid activities that will increase intraocular pressure
- E. Strabismus
- F. Glaucoma
Correct Answer: D
Rationale: The client is most likely experiencing diabetic retinopathy, a complication of poorly controlled type 1 diabetes. Calling for an ophthalmological exam and orienting the client to the environment address the condition, while monitoring blood glucose and visual acuity assess progress.
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The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns of dietary intake.
- B. Activity level of bowel sounds.
- C. Level and amount of physical activity.
- D. Color and consistency of feces.
Correct Answer: A
Rationale: Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure readings will be less than 160/90 mm Hg.
- B. The nurse will encourage the client to walk thirty minutes every day.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The client's daily blood pressure will be less than 140/80 mm Hg this month.
Correct Answer: D
Rationale: Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to reduce cardiovascular complications, including those contributing to blurred vision.
A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client's serum sodium level increases from 120 mEq/L to 125 mEq/L, which intervention should the nurse implement?
- A. Assess for increasing fluid volume overload.
- B. Withhold next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Maintain the prescribed fluid restriction.
Correct Answer: D
Rationale: Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.
The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
- A. Plan to assess the client's cognition after returning to the room.
- B. Confirm that this is an effective technique to help with ambulation.
- C. Assist the client to a carpeted area to walk more easily.
- D. Reorient the client to the present location and circumstances.
Correct Answer: B
Rationale: Confirming that the client's technique of pretending to step over a crack is an effective strategy acknowledges the client's self-initiated coping mechanism for freezing episodes, which can help promote independence in ambulation.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Avoid wearing tight fitting clothes.
- B. Minimize intake of spicy foods.
- C. Begin a smoking cessation program.
- D. Remain upright following meals.
Correct Answer: D
Rationale: Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter, minimizing reflux episodes.