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The following would be a symptom the nurse would expect to find during assessment of a patient with macular degeneration, EXCEPT:
- A. Decreased ability to distinguish colors
- B. Loss of central vision
- C. Loss of near vision
- D. Loss of peripheral vision
Correct Answer: D
Rationale: Macular degeneration primarily affects the macula, which is responsible for central vision. Therefore, symptoms typically include loss of central vision, decreased ability to distinguish colors, and loss of near vision. Loss of peripheral vision is not a common symptom associated with macular degeneration. Instead, it is more commonly seen in conditions affecting the peripheral retina, such as retinitis pigmentosa.
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.A client complains of urinary discomfort and a burning sensation while urinating. A urethral smear shows evidence of urethritis, and the client is prescribed antibiotics and instructed to drink 2-3 L of water daily. For which of the ff reasons is the client advised to drink the specified amount of water?
- A. It will help him overcome urinary incontinence
- B. It will promote renal blood flow and flush bacteria from the urinary tract
- C. It will help him eliminate urinary odors
- D. It will provide relief from pain and discomfort as a result of urinary tract infection DISTURBANCES IN FLUIDS AND ELECTROLYTES
Correct Answer: B
Rationale: The client is advised to drink 2-3 liters of water daily because it will promote renal blood flow and flush bacteria from the urinary tract. Increased water intake helps to dilute the urine, making it easier to flush out harmful bacteria that may be causing the urinary discomfort and urethritis. Adequate hydration is crucial for maintaining healthy urinary function and preventing urinary tract infections. By increasing water consumption, the client can help reduce the concentration of bacteria in the urinary tract, supporting the effectiveness of the prescribed antibiotics in treating the urethritis.
Mrs. Go is suspected of experiencing respiratory distress from a left-sided pneumothorax. She should be positioned:
- A. in a semi-fowler's position
- B. trendelenburg position
- C. prone position
- D. on the right side
Correct Answer: A
Rationale: Mrs. Go, who is suspected of experiencing respiratory distress from a left-sided pneumothorax, should be positioned in a semi-fowler's position. This position involves elevating the head of the bed to approximately 30 to 45 degrees. Placing the patient in a semi-fowler's position helps improve lung expansion, facilitates breathing, and promotes optimal oxygenation. It can also help prevent the collapse of the affected lung and assist in reducing the symptoms associated with pneumothorax. Trendelenburg position (B) and prone position (C) are not recommended for pneumothorax as they can worsen the condition by putting additional pressure on the affected lung. Placing the patient on the right side (D) would not specifically address the respiratory distress caused by a left-sided pneumothorax. Therefore, the most appropriate position for Mrs. Go in this situation is the semi-fowler's position.
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She's fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
- A. Deficient fluid volume related to inability to conserve water
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolic state
- C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
- D. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency
Correct Answer: C
Rationale: The client's elevated sodium level of 152 mEq/L indicates hypernatremia, which can lead to osmotic diuresis, causing excessive urination and subsequent fluid loss. This fluid loss can result in deficient fluid volume. The client's symptoms of frequent urination, fatigue from lack of sleep, and weight loss are indicative of dehydration due to the osmotic diuresis. Therefore, the most appropriate nursing diagnosis for this client is Deficient fluid volume related to osmotic diuresis induced by hypernatremia.
Which statement is true about smoking in adolescence?
- A. Smoking is related to other high-risk behaviors.
- B. Smoking will not continue unless peer pressure continues.
- C. Smoking is less common when the adolescent's parent(s) smokes.
- D. Smoking among adolescents is becoming more prevalent.
Correct Answer: A
Rationale: Research has shown that smoking during adolescence is closely linked to engaging in other high-risk behaviors, such as alcohol and drug use, risky sexual behavior, and delinquency. Adolescents who smoke are more likely to experiment with other substances and engage in risky activities compared to non-smokers. This is due to common psychological and sociocultural factors that contribute to the clustering of risky behaviors among adolescents. Therefore, statement A is the most accurate description of the relationship between smoking and high-risk behaviors in adolescence.
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: When auscultating the lungs of a client with pleural effusion, the examiner would note sounds consistent with fluid accumulation in the pleural space. This includes decreased or absent breath sounds over the area where the effusion is present. The presence of fluid in the involved area may cause a dullness to percussion as well. Pronounced breath sounds and expiratory wheezes are not typically associated with pleural effusion. While a friction rub may be heard in conditions such as pleurisy, it is not specific to pleural effusion.