Nokea
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: The correct answer is D, Arcus senilis. This condition does not cause visual problems in the older adult. Arcus senilis is a grayish-white ring around the cornea, which does not affect vision. Glaucoma, macular degeneration, and cataracts are conditions that can lead to visual impairment in older adults. Glaucoma is characterized by increased pressure in the eye, which can damage the optic nerve and lead to vision loss. Macular degeneration affects the central part of the retina, leading to blurred or distorted vision. Cataracts cause clouding of the lens, resulting in decreased vision. Therefore, Arcus senilis is the correct choice as it does not cause visual problems compared to the other conditions listed.
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Which finding is an early indicator of bladder cancer?
- A. Painless hematuria
- B. Nocturia
- C. Occasional polyuria
- D. Dysuria
Correct Answer: A
Rationale: The correct answer is A: Painless hematuria. This is an early indicator of bladder cancer because blood in the urine without pain is a common symptom in the early stages of the disease. Nocturia (B), frequent urination at night, is more commonly associated with urinary tract infections or benign prostatic hyperplasia. Occasional polyuria (C), excessive urination, can be a symptom of diabetes or kidney disease. Dysuria (D), painful urination, is more indicative of urinary tract infections or urethritis. Therefore, painless hematuria is the most specific early indicator of bladder cancer among the choices provided.
Which of the following nursing activities is an example of evaluation?
- A. Checking a client’s blood pressure 30 minutes after administering an antihypertensive medication
- B. Administering prescribed oxygen therapy to a client
- C. Developing a plan of care for a new client
- D. Teaching a client about low-sodium dietary options
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
- A. tachycardia
- B. hyperthermia
- C. weight loss
- D. extreme fatigue
Correct Answer: D
Rationale: The correct answer is D, extreme fatigue, for a patient suspected of having hypothyroidism. Hypothyroidism is associated with decreased production of thyroid hormones, leading to a slower metabolism and reduced energy levels. This results in symptoms such as fatigue, weakness, and lethargy. Tachycardia (A) is more commonly associated with hyperthyroidism, where the thyroid is overactive. Hyperthermia (B) is increased body temperature, not typically a symptom of hypothyroidism. Weight loss (C) is also more commonly seen in hyperthyroidism due to increased metabolism. In summary, extreme fatigue is a hallmark symptom of hypothyroidism due to decreased thyroid hormone levels, distinguishing it from the other choices.
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
- A. Urine glucose level
- B. Serum fructosamine level
- C. Fasting blood glucose level
- D. Glycosylated hemoglobin level
Correct Answer: D
Rationale: The correct answer is D: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. It is a more reliable indicator compared to other options. A: Urine glucose level only shows current glucose levels and is not a reliable indicator of long-term control. B: Serum fructosamine level reflects blood glucose control over the past 2-3 weeks, not the 3-month period the client has been making efforts. C: Fasting blood glucose level gives a snapshot of the current glucose level, not long-term control like glycosylated hemoglobin does.
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.