Nokea
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.
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A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?
- A. Deficient fluid volume.
- B. Intestinal obstruction.
- C. Bowel ischemia.
- D. Peritonitis.
Correct Answer: D
Rationale: Fever, tachycardia, and hypotension in acute appendicitis suggest peritonitis, a complication from possible appendiceal rupture. Deficient fluid volume, obstruction, or ischemia are less directly indicated by these signs. CN: Physiological adaptation; CL: Analyze
Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirl pool bath and dressing change?
- A. Soak the dressing.
- B. Remove the dressing.
- C. Administer an analgesic.
- D. Slit the dressing with blunt scissors.
Correct Answer: C
Rationale: Administering an analgesic 30 minutes before a painful procedure like a whirlpool bath and dressing change ensures pain relief, improving patient comfort and cooperation. Soaking, removing, or slitting the dressing typically occurs during the procedure, not beforehand.
When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs?
- A. Nasogastric drainage.
- B. Urinary catheter.
- C. Dressing.
- D. Need for pain medication.
Correct Answer: C
Rationale: After a splenectomy, the nurse should assess the dressing for signs of bleeding, as the spleen is highly vascular, and postoperative hemorrhage is a risk. Nasogastric drainage, urinary output, and pain are assessed later, but the dressing is the priority to detect complications.
The nurse should remind family members who are visiting a client with granulocytopenia to:
- A. Visit only if they do not have a cold.
- B. Wash their hands.
- C. Leave the children at home.
- D. Avoid kissing the client on the lips.
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent transmission of pathogens to a granulocytopenic client, who is at high risk for infection. While avoiding colds, leaving children at home, and avoiding kissing are helpful, hand washing is the priority.
The incidence and risk of cancer increase when smoking is combined with:
- A. Asbestos exposure and alcohol consumption.
- B. Ultraviolet radiation exposure and alcohol consumption.
- C. Asbestos exposure and ultraviolet radiation exposure.
- D. Alcohol consumption and human papillomavirus (HPV) infection.
Correct Answer: A
Rationale: Smoking combined with asbestos exposure and alcohol consumption significantly increases cancer risk, particularly for lung and head/neck cancers, due to synergistic carcinogenic effects.