Nokea
Mrs. Blakely's postoperative course is otherwise uneventful, and she is fitted with corrective glasses. For Mrs. Blakely to adjust to wearing her new eyeglasses, it would be most important to teach her that
- A. the color of objects seen with the operated eye is much brighter
- B. her new glasses will be much heavier
- C. she will have binocular vision
- D. she will have considerable distortion in vision
Correct Answer: A
Rationale: After cataract surgery, colors may appear brighter due to the removal of the cloudy lens, which previously muted perception of certain wavelengths.
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While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
- A. Atelectasis
- B. Flail chest
- C. Hemothorax
- D. Pneumothorax
Correct Answer: B
Rationale: The correct answer is B: Flail chest. Flail chest occurs when a segment of the rib cage is detached from the rest of the chest wall, causing paradoxical chest movement. In this case, the inward movement during inspiration and outward bulging during expiration are classic signs of flail chest, as the detached segment moves in the opposite direction of the rest of the chest wall. Atelectasis (choice A) refers to collapsed lung tissue, not paradoxical chest movement. Hemothorax (choice C) is the accumulation of blood in the pleural space, which does not cause paradoxical chest movement. Pneumothorax (choice D) is the presence of air in the pleural space, which can cause chest pain and dyspnea but does not result in paradoxical chest movement.
Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include:
- A. Elevated RBC and elevated respiratory rate.
- B. Elevated WBC and elevated temperature.
- C. Elevated erythrocyte sedimentation rate and decreased pulse.
- D. Decreased platelets and decreased blood pressure.
Correct Answer: B
Rationale: Elevated white blood cell (WBC) count and fever are classic signs of infection. These indicators suggest the body is mounting an immune response to a potential pathogen.
The nurse knows that the most likely cause of the HSV-1 infection in a client with HIV infection is:
- A. Immunosuppression.
- B. Emotional stress.
- C. Unprotected sexual activities.
- D. Contact with saliva.
Correct Answer: A
Rationale: HSV-1 thrives in immunocompromised individuals due to weakened immune defenses.
What is the treatment for viral conjunctivitis?
- A. Antibiotic drops
- B. Steroid drops
- C. Supportive care
- D. Surgical intervention
Correct Answer: C
Rationale: Viral conjunctivitis typically resolves with supportive care, such as artificial tears and cold compresses.
What are the priority medical interventions for a client experiencing shock?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.