Nokea
The client is diagnosed in the emergency department with a detached retina in the right eye. The nurse should do which of the following first?
- A. Apply compresses to the eye.
- B. Administer analgesics to reduce pain.
- C. Remove all bed pillows.
- D. Promote measures that limit mobility.
Correct Answer: D
Rationale: Limiting mobility is the priority to prevent further detachment of the retina by reducing eye movement and strain until surgical intervention can be performed.
You may also like to solve these questions
The client with lymphedema has an increased risk of cellulitis and lymphangitis because of:
- A. Fragility of the capillaries.
- B. Myelosuppression of the bone marrow.
- C. Stagnation of accumulated fluid.
- D. Increased use of the extremity.
Correct Answer: C
Rationale: Stagnation of accumulated fluid in lymphedema creates an environment conducive to bacterial growth, increasing the risk of cellulitis and lymphangitis.
Thirty people are injured in a train derailment. Ineffective and the transported to the hospital first?
- A. A 20-year-old who is unresponsive and has a high injury to his spinal cord.
- B. An 80-year-old who has a compound fracture of the arm.
- C. A 10-year-old with a laceration on his leg.
- D. A 25-year-old with a sucking chest wound.
Correct Answer: D
Rationale: A sucking chest wound is a life-threatening condition that can impair breathing and requires immediate intervention, prioritizing this patient for transport over others with less urgent injuries.
The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, 'I'm upset because I know I won't be able to have children now that I have an ileostomy.' Which of the following would be the best response for the nurse?
- A. Many women with an ileostomy can still have children; let's discuss your concerns with your doctor.
- B. Having an ileostomy does prevent pregnancy, but you can explore adoption.
- C. This is a common feeling; would you like to talk more about it?
- D. I'll RAW arrange for a counselor to discuss your fertility options.
Correct Answer: A
Rationale: The nurse should reassure the client that many women with ileostomies can still have children and offer to discuss this with the doctor, addressing the misconception directly. The other options either reinforce the misconception, avoid the concern, or defer without providing immediate support. CN: Psychosocial adaptation; CL: Synthesize
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
- A. The client has a sore throat.
- B. The client appears drowsy following the procedure.
- C. The client has epigastric pain.
- D. The client experiences hematemesis.
Correct Answer: C,D
Rationale: Epigastric pain and hematemesis after a gastroscopy may indicate complications such as perforation or bleeding. A sore throat and drowsiness are expected post-procedure effects due to throat irritation and sedation.