Nokea
The nurse is caring for a client with suspected retinal detachment. Which of the following manifestations would not be consistent with a diagnosis of retinal detachment?
- A. Seeing 'floaters' in the field of vision
- B. A sense of having a curtain drawn over the eyes
- C. Flashes of light
- D. Intense pain in the affected eye
Correct Answer: D
Rationale: Retinal detachment typically presents with floaters, a curtain-like shadow, and flashes of light due to the retina pulling away from the underlying tissue. Intense pain is not a common symptom, as retinal detachment is usually painless.
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A client in a hospice program has increasing pain. The nurse and client collaborate to schedule analgesics to provide which of the following?
- A. Doses of analgesic when pain is a '5' on a scale of 1-10.
- B. Enough analgesia to keep the client semisomnolent.
- C. An analgesia-free period so that the client can carry out daily hygienic activities.
- D. Around-the-clock routine administration of analgesics for continuous pain relief.
Correct Answer: D
Rationale: Around-the-clock administration of analgesics ensures continuous pain relief, which is critical for hospice patients with persistent pain, preventing pain escalation.
The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:
- A. 170 calories.
- B. 250 calories.
- C. 340 calories.
- D. 500 calories.
Correct Answer: A
Rationale: One liter of 5% dextrose provides 50 g of dextrose, yielding approximately 170 calories, insufficient for full nutritional needs.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first?
- A. Tell the client it is impossible to feel the pain.
- B. Show the client that the toes are not there.
- C. Explain to the client that her pain is real.
- D. Give the client the prescribed opioid analgesic.
Correct Answer: C
Rationale: Phantom limb pain is real and distressing; acknowledging it validates the client's experience.
A 62-year-old male with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused client assessment for:
- A. Ascites.
- B. Pleural friction rub.
- C. Dyspnea.
- D. Peripheral edema.
Correct Answer: C
Rationale: Dyspnea is a priority assessment for a client with COPD and metastatic lung cancer, as it is a common and distressing symptom requiring palliation in hospice care.
Doxorubicin (Adriamycin) is prescribed for a female client with breast cancer. The client is distressed about hair loss. The nurse should do which of the following?
- A. Have the client wash and massage the scalp daily to stimulate hair growth.
- B. Explain that hair loss is temporary and will quickly grow back to its original appearance.
- C. Provide resources for a wig selection before hair loss begins.
- D. Recommend that the client limit social contacts until hair regrows.
Correct Answer: C
Rationale: Providing resources for wig selection before hair loss begins helps the client prepare for and cope with chemotherapy-induced alopecia, maintaining her self-esteem.