Nokea
The nurse is assessing a client with drooping of their left eyelid. The nurse documents this finding as
- A. mydriasis.
- B. ptosis.
- C. presbyopia.
- D. hyphema.
Correct Answer: B
Rationale: Ptosis is the medical term for drooping of the eyelid. Mydriasis refers to pupil dilation, presbyopia is age-related vision loss, and hyphema is blood in the anterior chamber of the eye.
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The nurse is preparing to administer medication to a client. After verifying the right medication, dose, route, and time, the nurse should
- A. confirm the client's identity using two client identifiers.
- B. explain the purpose and potential side effects of the medication to the client.
- C. ensure the medication is within its expiration date.
- D. document the medication administration in the client's medical record.
Correct Answer: A
Rationale: Confirming client identity is the next step after verifying medication details to ensure safety.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply.
- A. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals.
- B. Choose good calcium sources, such as figs, broccoli, and almonds.
- C. Use alcohol in moderation because a moderate intake has no known negative effects.
- D. None of the above
Correct Answer: A,B
Rationale: Vitamin D and calcium are essential for bone health. Excessive alcohol can reduce bone density, so moderation alone is insufficient.
A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now 'unable to concentrate at her card game' and 'it seems harder and harder to finish her errands because of exhaustion.' Based on this information, the nurse should suggest that the client do which of the following?
- A. Take frequent naps.
- B. Limit activities.
- C. Increase fluid intake.
- D. Avoid contact with others.
Correct Answer: A
Rationale: The client's symptoms of difficulty concentrating and exhaustion suggest fatigue, which is a common long-term side effect of chemotherapy. Taking frequent naps can help manage fatigue by allowing the client to rest and conserve energy, improving her ability to perform daily activities. Limiting activities may be overly restrictive and not address the root issue, increasing fluid intake is not directly related to fatigue unless dehydration is present, and avoiding contact with others is unnecessary unless there is an infection risk.
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan?
- A. Restrict fluids to 1,000 mL/24 hours.
- B. Drink 400 to 500 mL with each meal.
- C. Drink fluids midmorning, midafternoon, and late afternoon.
- D. Attempt to void at least every 2 hours.
- E. Use intermittent catheterization as needed.
Correct Answer: B,C,D,E
Rationale: Drinking 400-500 mL with meals (B), timing fluids (C), voiding every 2 hours (D), and using intermittent catheterization (E) promote bladder control. Restricting fluids to 1,000 mL/day risks dehydration and is inappropriate.