Nokea
Mrs. Blakely had an intracapsular extraction yesterday. Early this morning she complained of eye pain and nausea after breakfast while continuing to complain of eye pain. Your analysis of the situation is that Mrs. Blakely is
- A. unable to tolerate a regular diet this soon postoperatively
- B. allergic to the pain medication
- C. experiencing increased intraocular pressure
- D. exhibiting symptoms of postoperative infection
Correct Answer: C
Rationale: Severe eye pain accompanied by nausea following cataract surgery suggests elevated intraocular pressure, which must be addressed promptly to prevent complications.
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Which of the following is the priority nursing diagnosis?
- A. Risk for Infection related to organisms specific to cat bites
- B. Impaired Skin Integrity related to puncture wounds
- C. Ineffective Health Maintenance related to immunization status
- D. Risk for Impaired Mobility related to potential tendon damage
Correct Answer: A
Rationale: Cat bites carry a high risk of infection due to the bacteria present in their mouths.
Identify one example of how each of the following cultural factors may affect the nursing care of a patient of a different culture and one example of the functioning of a health care team made up of individuals from different cultures.
- A. Time orientation
- B. Economic factors
- C. Nutrition
- D. Personal space
Correct Answer: D
Rationale: This question requires subjective examples based on individual interpretation. For instance, time orientation might influence punctuality expectations in patients and collaboration within diverse teams.
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Oxygen saturation of 95%
- B. No fluctuations in the water seal chamber
- C. No reports of pleuritic chest pain
- D. Occasional bubbling in the water-seal chamber
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.
Karen is suspected of having a hormone imbalance. What would you expect to monitor
- A. Electrolyte levels.
- B. Thyroid studies, follicle-stimulating hormone (FSH), and luteinizing hormone (LH).
- C. Caloric intake.
- D. All of the above.
Correct Answer: D
Rationale: Hormonal imbalances affect multiple systems and require comprehensive monitoring.
Mrs. Roberts communicates very well by lipreading. In planning Mrs. Roberts' care, it is important to
- A. face her and slightly raise your voice
- B. write everything important
- C. employ nonverbal cues to help convey your meaning
- D. avoid obscuring her view of your mouth
Correct Answer: D
Rationale: Clear visibility of the speaker's mouth is vital for effective lipreading, ensuring accurate communication.