Nokea
During a discussion about glaucoma at the community center, which comment by one of the retirees would the nurse give a supportive comment to reinforce correct information?
- A. ''I usually avoid driving at night since lights sometimes seem to make things blur.''
- B. ''I take half of the usual dose for my sinuses to maintain my blood pressure.''
- C. ''I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.''
- D. ''I take extra fiber and drink lots of water to avoid getting constipated.''
Correct Answer: D
Rationale: The correct answer is ''I take extra fiber and drink lots of water to avoid getting constipated.'' In individuals with glaucoma, activities that involve straining, such as constipation, should be avoided as they can increase intraocular pressure. Choices A, B, and C are incorrect as they do not align with the management of glaucoma. Driving at night or taking sinus medication are not directly related to glaucoma, and sitting by the pool due to an eye problem does not provide information relevant to managing glaucoma.
You may also like to solve these questions
What step should be taken when administering ear drops to an adult client?
- A. Place the client in a side-lying position.
- B. Hold the dropper 1 cm above the ear canal.
- C. Place a cotton ball into the outermost canal.
- D. Pull the auricle down and back.
Correct Answer: A
Rationale: The correct step when administering ear drops to an adult client is to place the client in a side-lying position (A). This position allows for easier administration of the drops and helps prevent spillage. The dropper should be held approximately 1 cm (½ inch) above the ear canal (B) to ensure accurate delivery of the medication. Placing a cotton ball into the outermost canal (C) is unnecessary and may interfere with the absorption of the ear drops. Pulling the auricle down and back (D) is a technique used for children younger than 3 years old to straighten the ear canal, but it is not necessary for adults and may cause discomfort.
When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Re-inflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct Answer: C
Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
- A. Assist the client to walk to the bathroom and do not leave the client alone.
- B. Request that the UAP assist the client onto a bedpan.
- C. Ask if the client needs to have a bowel movement or void.
- D. Assess the client's bladder to determine if the client needs to urinate.
Correct Answer: A
Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. Therefore, the nurse should assist the client to the bathroom to ensure safety. Using a bedpan is not necessary if the client can safely walk to the bathroom. Asking about bowel movements or voiding, as in option C, is irrelevant to the immediate safety concern of assisting the client to the bathroom. Assessing the client's bladder, as in option D, is unnecessary in this situation as there is no indication that the client cannot communicate his or her needs effectively. The priority here is to prevent falls and ensure the client's safety while assisting to the bathroom.
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?
- A. White blood cell count
- B. Albumin
- C. Calcium
- D. Sodium
Correct Answer: D
Rationale: The nurse should monitor the client's serum sodium levels carefully when they have been on nasogastric (NG) tube suction for an extended period. Prolonged NG suctioning can lead to fluid loss and subsequent hyponatremia. Monitoring sodium levels is crucial to prevent complications. White blood cell count (Option A), albumin (Option B), and calcium (Option C) are not typically affected by prolonged NG suctioning. Therefore, these values are not the priority for monitoring in this situation.
Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?
- A. A client follows the therapist's finger with their eyes while focusing on a negative thought or memory
- B. A client reads a story about a traumatic event and then visualizes the result
- C. A client focuses on a negative thought in their mind while tapping their fingers
- D. None of the above
Correct Answer: A
Rationale: Eye Movement Desensitization and Reprocessing (EMDR) is a therapeutic approach used to address negative thoughts or traumatic memories, particularly in individuals with post-traumatic stress disorder. During EMDR, the client concentrates on a distressing thought or memory and the associated emotions while engaging in bilateral stimulation, often by moving their eyes back and forth. This bilateral stimulation can involve tracking the therapist's finger or other forms of sensory stimulation. Choice A is correct as it accurately describes the core process of EMDR. Choices B and C are incorrect as they do not involve the essential components of EMDR, which include eye movements or bilateral stimulation. Choice D is incorrect as EMDR is a specific therapeutic technique and not covered by selecting 'None of the above'.