Nokea
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client:
- A. Selects a low-cholesterol diet to control coronary artery disease.
- B. States a need for bed rest for 1 week after discharge.
- C. Verbalizes safety precautions needed to prevent pacemaker malfunction.
- D. Explains signs and symptoms of myocardial infarction (MI).
Correct Answer: C
Rationale: Understanding safety precautions (e.g., avoiding strong electromagnetic fields) prevents pacemaker malfunction, indicating discharge plan comprehension.
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A client is scheduled for a renal ultrasound. The nurse explains that:
- A. Contrast dye is used.
- B. No preparation is needed.
- C. Fasting is required.
- D. A sedative is given.
Correct Answer: B
Rationale: Renal ultrasound is non-invasive and requires no special preparation.
The nurse is assessing a client with age-related cataracts. Which of the following assessment findings would support this diagnosis of age-related cataracts?
- A. peripheral vision loss
- B. central vision loss
- C. difficulty seeing at night, especially while driving
- D. blurred vision with headache
Correct Answer: C
Rationale: Age-related cataracts often cause difficulty seeing at night, particularly while driving, due to lens opacity scattering light. Peripheral vision loss is more associated with glaucoma, central vision loss with macular degeneration, and blurred vision with headache is typical of angle-closure glaucoma.
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.
Which of the following will the nurse observe in the ictal phase of a generalized tonic-clonic seizure?
- A. Linking in one extremity that spreads gradually to adjacent areas.
- B. Vacant staring and abruptly ceasing all activity.
- C. Facial grimaces, patting motions, and lip smacking.
- D. Loss of consciousness, body stiffening, and violent muscle contractions.
Correct Answer: D
Rationale: The ictal phase of a generalized tonic-clonic seizure is characterized by loss of consciousness, body stiffening (tonic phase), and violent muscle contractions (clonic phase). The other options describe focal or absence seizures.
Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the following is the most appropriate nursing action?
- A. Insert a straight catheter.
- B. Increase I.V. fluids.
- C. Notify the surgeon.
- D. Assist the client to the bathroom.
Correct Answer: A
Rationale: A distended bladder and inability to void suggest urinary retention, common post-surgery. Inserting a straight catheter relieves the bladder and prevents complications like overdistension.