Nokea
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. A nystagmus on the left.
- B. Exophthalmos on the right.
- C. Ptosis on the left eyelid.
- D. Astigmatism on the right.
Correct Answer: C
Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid.
Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.
You may also like to solve these questions
The condition of a critically ill patient with a living will has deteriorated. The patient’s partner wants “everything done,” regardless of the patient’s wishe s. Which ethical principle is the partner violating?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Nonmaleficence
Correct Answer: A
Rationale: The correct answer is A: Autonomy. Autonomy is the ethical principle that respects an individual's right to make decisions about their own care and treatment. In this scenario, the partner wanting "everything done" regardless of the patient's wishes violates the patient's autonomy by not honoring their previously expressed wishes outlined in the living will. This decision disregards the patient's right to make choices about their own healthcare. Choices B, C, and D are incorrect because:
B: Beneficence focuses on doing good for the patient, but in this case, the partner's actions are not necessarily in the patient's best interest.
C: Justice pertains to fairness and equal treatment, which is not directly relevant to the situation described.
D: Nonmaleficence is the principle of doing no harm, but in this scenario, the harm is not necessarily physical but rather a violation of the patient's autonomy.
The AACN Standards for Acute and Critical Care Nursing Practice uses what framework to guide critical care nursing practice?
- A. Evidence-based practice
- B. Healthy work environment
- C. National Patient Safety Goals
- D. Nursing process
Correct Answer: A
Rationale: The correct answer is A: Evidence-based practice. The AACN Standards for Acute and Critical Care Nursing Practice emphasize the use of evidence-based practice to guide critical care nursing. This framework ensures that nursing interventions are based on the best available evidence, leading to improved patient outcomes. Healthy work environment (B) and National Patient Safety Goals (C) are important but not specific frameworks for critical care nursing. The nursing process (D) is a systematic approach to delivering patient care but is not the primary guiding framework in critical care nursing practice.
The nurse is caring for a patient diagnosed with hyperactivaebi rdb.ecloimri/tuemst . The nurse focuses interventions toward which priority need?
- A. Comfort
- B. Nourishment
- C. Safety
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.
A hospital interviews two different candidates for a position in the ICU. Both candidates have around 10 years of experience working in the ICU. Both have excellent interpersonal skills and highly positive references. One, however, has certification in critical care nursing. Which of the following is the most compelling and accurate reason for the hospital to hire the candidate with certification?
- A. The certified nurse will have more knowledge and expertise.
- B. The certified nurse will behave more ethically.
- C. The certified nurse will be more caring toward patients.
- D. The certified nurse will work more collaboratively with other nurses.
Correct Answer: A
Rationale: The correct answer is A: The certified nurse will have more knowledge and expertise. Certification in critical care nursing indicates that the candidate has undergone specialized training and passed a standardized exam, demonstrating a higher level of knowledge and skill in critical care practices compared to a non-certified candidate. This certification ensures that the nurse has met specific competency standards in critical care, making them better equipped to handle complex situations in the ICU.
Summary:
- Choice B (ethical behavior) and Choice C (caring towards patients) are subjective qualities that can be present in both certified and non-certified nurses.
- Choice D (collaboration with other nurses) is not directly related to certification but can be influenced by the individual's interpersonal skills.
- Ultimately, the certification in critical care nursing provides concrete evidence of the candidate's advanced knowledge and expertise, making them the most compelling choice for the hospital to hire.
The nurse is assessing the exhaled tidal volume (EV ) in a mechanically ventilated patient. T What is the rationale for this assessment?
- A. Assess for tension pneumothorax.
- B. Assess the level of positive end-expiratory pressure.
- C. Compare the tidal volume delivered with the tidal volu me prescribed.
- D. Determine the patient’s work of breathing.
Correct Answer: D
Rationale: The correct answer is D: Determine the patient’s work of breathing. Assessing the exhaled tidal volume (EV) in a mechanically ventilated patient helps determine how much effort the patient is exerting to breathe. By monitoring the EV, the nurse can evaluate the patient's respiratory status and adjust ventilator settings if needed. It is crucial to ensure that the patient is not working too hard to breathe, as this can lead to respiratory distress.
Incorrect answers:
A: Assess for tension pneumothorax - Tension pneumothorax is typically assessed through other means such as physical examination and chest X-ray.
B: Assess the level of positive end-expiratory pressure - The level of positive end-expiratory pressure is usually set based on the patient's condition and not solely based on the exhaled tidal volume.
C: Compare the tidal volume delivered with the tidal volume prescribed - This comparison is important but does not directly relate to assessing the patient's work of breathing.