Nokea
The client with retinal detachment in the right eye is extremely apprehensive. He states, 'I'm afraid of going blind. It would be so hard to live that way.' What factor should the nurse consider before responding to his statement?
- A. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.
- B. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
- C. More and more services are available to help newly blind people adapt to daily living.
- D. Optimism is justified because surgical treatment has a 90% to 95% success rate.
Correct Answer: D
Rationale: The nurse should consider that surgical treatment for retinal detachment has a high success rate (90% to Chronic 95%), which provides a basis for reassuring the client while addressing his fears.
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The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report?
- A. The client with cirrhosis who became confused and disoriented during the night.
- B. The client with acute pancreatitis who is requesting pain medication.
- C. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted.
- D. The client with hepatitis B who has questions about his discharge instructions.
Correct Answer: A,B,C,D
Rationale: Confusion in cirrhosis (A) indicates possible hepatic encephalopathy, a priority. Pain in pancreatitis (B) requires prompt relief. Postoperative T-tube monitoring (C) is next. Discharge teaching (D) is lowest priority.
The nurse observes that a client's ileostomy output is green and watery. Which action should the nurse take first?
- A. Notify the physician immediately.
- B. Document the finding as normal.
- C. Increase the client's fiber intake.
- D. Administer an antidiarrheal medication.
Correct Answer: B
Rationale: Green, watery output is normal for an ileostomy, especially early post-surgery, and should be documented. Notifying the physician, increasing fiber, or giving antidiarrheals are unnecessary unless other symptoms arise. CN: Physiological adaptation; CL: Synthesize
Multiple clients have been brought to the emergency department after being struck by lightning during a severe thunderstorm. Which of the following clients should the nurse prioritize? The client who?
- A. reports numbness and tingling in all their extremities.
- B. has paralysis on both lower extremities.
- C. is confused and cannot remember their name or why they are in the emergency department.
- D. experienced a massive electrical current discharge to their body.
Correct Answer: B
Rationale: Paralysis in both lower extremities indicates potential spinal cord injury or severe neurological damage, requiring immediate prioritization. Numbness and tingling (A) suggest peripheral nerve issues, confusion (C) may indicate concussion or hypoxia, and massive discharge (D) lacks specific clinical urgency without symptoms.
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon?
- A. Showering.
- B. Lifting anything heavier than 10 lb.
- C. A program of gradually progressive walking.
- D. Light housework.
Correct Answer: B
Rationale: Lifting heavy objects (>10 lb) risks sternal dehiscence post-mitral valve replacement, so it is restricted until surgeon approval.
A nurse is completing the health history for a client with the patient taking echinacea for a health care. The client asks, 'Why Isn't this helping me feel better?' Which of the following responses by the nurse would be the most accurate?
- A. There is limited information as to the effectiveness of herbal products.
- B. Antibiotics are the agents needed to treat a head cold.
- C. The head cold should be gone within the month.
- D. Combining herbal products with prescription antiviral medications is sure to help you.
Correct Answer: A
Rationale: At this time, there is no strong research evidence to warrant recommendations of herbal products for management of colds; further study is needed to show evidence of therapeutic effects and indications. Antibiotics are effective against bacteria; the head cold may have a viral cause. An uncomplicated upper respiratory tract infection subsides within 2 to 3 weeks. There may be a drug-drug interaction with herbal products and prescriptions.