Nokea
On inspection, which client does the nurse suspect of having a visual impairment?
- A. The client whose sclera is white
- B. The client who has an intact blink reflex
- C. The client who is tilting their head
- D. The client with equal pupils
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse educates a client about how to reduce their risk for osteoporosis. Which of these statements by the nurse is correct? (Select all that apply)
- A. You can decrease your risk of osteoporosis by avoiding vitamin D.
- B. You can decrease your risk of osteoporosis by reducing caffeine intake.
- C. You can decrease the risk of osteoporosis by decreasing alcohol intake.
- D. You can decrease your risk of osteoporosis by reducing protein intake.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?
- A. The UAP puts shoes on the client
- B. The UAP removes floor rugs and loose objects from the path
- C. The UAP walks to the side and slightly in front of the client
- D. The UAP uses a transfer (gait) belt
Correct Answer: C
Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.
What activities should the client avoid after cataract surgery? (Select all that apply)
- A. Blowing one's nose
- B. Bearing down during defecation
- C. Lifting items heavier than 10 pounds
- D. All of the Above
Correct Answer: D
Rationale: After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one's nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.
What health teaching would not help an older adult avoid a musculoskeletal injury?
- A. Avoid home modification
- B. Wear a helmet when riding a bicycle
- C. Osteoporosis screening
- D. Fall prevention
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.