Nokea
The nurse is assessing a client who has a suspected retinal detachment. Which of the following client statements would be consistent with this diagnosis?
- A. My vision has a cloudy appearance.'
- B. I have intense pain above my eyebrow.'
- C. I am having difficulty seeing while driving at night.'
- D. I can see bright flashes of light.'
Correct Answer: D
Rationale: Bright flashes of light are a hallmark symptom of retinal detachment due to vitreoretinal traction. Cloudy vision is more typical of cataracts, intense pain is not common, and night vision difficulty is not specific to retinal detachment.
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The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications?
- A. Detached retina.
- B. Prolapse of the iris.
- C. Extracapsular erosion.
- D. Intraocular hemorrhage.
Correct Answer: D
Rationale: Sharp pain in the operative eye post-cataract surgery may indicate intraocular hemorrhage, which can increase intraocular pressure and cause severe pain, requiring immediate intervention.
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.
A client with a suspected small bowel obstruction reports severe pain and vomiting. Which diagnostic test should the nurse prepare the client for first?
- A. Abdominal X-ray.
- B. Barium enema.
- C. Colonoscopy.
- D. CT scan.
Correct Answer: A
Rationale: An abdominal X-ray is typically the first diagnostic test for a suspected small bowel obstruction to identify air-fluid levels or free air. Barium enema and colonoscopy are contraindicated in acute obstruction, and a CT scan may follow for detailed imaging. CN: Reduction of risk potential; CL: Synthesize
The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
- A. Relief of anxiety
- B. Sedation
- C. Vasoconstriction
- D. Vasodilation
Correct Answer: D
Rationale: Diltiazem, a calcium channel blocker, promotes vasodilation in PVD, improving blood flow and reducing claudication symptoms. The nurse assesses for vasodilation (e.g., reduced pain, warmer extremities). It does not primarily relieve anxiety, cause sedation, or promote vasoconstriction.