Nokea
The nurse is performing a physical assessment on a client. To assess the client's visual acuity, the nurse would use a
- A. Snellen chart.
- B. tonometer device.
- C. penlight.
- D. slit lamp.
Correct Answer: A
Rationale: The Snellen chart is used to assess visual acuity by testing distance vision. A tonometer measures intraocular pressure, a penlight examines pupil response, and a slit lamp evaluates eye structures.
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An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client?
- A. Use a nightlight in the bathroom.
- B. Keep all four side rails up at all times.
- C. Place the client in a room with a camera monitor.
- D. Place the client in a room with a camera monitor.
Correct Answer: A
Rationale: A nightlight reduces fall risk by improving visibility during nighttime bathroom trips, suitable for an alert client. Four side rails are a restraint and unsafe.
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.
Which of the following dietary measures would be useful in preventing esophageal reflux?
- A. Eating small, frequent meals.
- B. Increasing fluid intake.
- C. Avoiding air swallowing with meals.
- D. Adding a bedtime snack to the dietary plan.
Correct Answer: A
Rationale: Small, frequent meals reduce gastric distention and lower the risk of reflux compared to large meals. The other options are less effective or may worsen symptoms.
Which of the following is a potential complication following cataract surgery? Select all that apply.
- A. Acute bacterial endophthalmitis.
- B. Retrobulbar hemorrhage.
- C. Rupture of the posterior capsule.
- D. Suprachoroidal hemorrhage.
- E. Vision loss.
Correct Answer: A,B,C,D,E
Rationale: Potential complications after cataract surgery include acute bacterial endophthalmitis (infection), retrobulbar hemorrhage (bleeding behind the eye), rupture of the posterior capsule (lens capsule tear), suprachoroidal hemorrhage (bleeding in the choroid), and vision loss due to these or other complications.
A nurse is assessing a group of clients. Which clients are at risk for vasospastic disorder (Raynaud's phenomenon)?
- A. Young women
- B. Old women
- C. Old men
- D. Young men
Correct Answer: A
Rationale: Young women are at highest risk for Raynaud's phenomenon, particularly primary Raynaud's, due to hormonal influences and higher prevalence of autoimmune conditions. While men and older individuals can develop it, young women are most commonly affected.