Nokea
The nurse is performing an assessment on an older client. Which signs/symptoms are age-related changes in the eye? Select all that apply.
- A. Clear sclera
- B. Blurred vision
- C. Protruding cornea
- D. Increased tear production
- E. Diminished pupillary adaptation to darkness
- F. Increased ability to discriminate among colors
Correct Answer: B,E
Rationale: Age-related changes in the eye include flattening of the cornea, which causes blurred vision; poor pupillary adaptation to darkness; yellowing sclera; a sunken appearance; diminished tear production; diminished ability to discriminate among colors; and reduced ocular muscle strength.
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The nurse is preparing a client diagnosed with pneumonia for discharge. Which statement by the client should alert the nurse to the fact that the client needs further teaching before being discharged?
- A. I will take all of my antibiotics, even if I do feel 100% better.
- B. You can toss out that incentive spirometer as soon as I leave for home.
- C. I realize that it may be weeks before my usual sense of well-being returns.
- D. It is a good idea for me to take a nap every afternoon for the next couple of weeks.
Correct Answer: B
Rationale: Deep breathing and coughing exercises and the use of incentive spirometry should be practiced for 6 to 8 weeks after the client diagnosed with pneumonia is discharged from the hospital to keep the alveoli expanded and promote the removal of lung secretions. If the entire regimen of antibiotics is not taken, the client may suffer a relapse. The period of convalescence with pneumonia is often lengthy, and it may be weeks before the client feels a sense of well-being. Adequate rest is needed to maintain progress toward recovery.
A child with a diagnosis of umbilical hernia has been scheduled for surgical repair in 2 weeks. The clinic nurse instructs the parents about the signs of possible hernia strangulation. The nurse tells the parents that which sign requires primary health care provider notification?
- A. Fever
- B. Diarrhea
- C. Vomiting
- D. Constipation
Correct Answer: C
Rationale: The parents of a child with an umbilical hernia need to be instructed regarding the signs/symptoms of strangulation, which include vomiting, pain, and an irreducible mass at the umbilicus. Fever, diarrhea, and constipation are not signs of hernia strangulation. The parents should be instructed to contact the primary health care provider immediately if strangulation is suspected.
The nurse is teaching a client who had been newly diagnosed with diabetes mellitus about blood glucose monitoring. The nurse should teach the client to report glucose levels that consistently exceed which level?
- A. 150 mg/dL (8.57 mmol/L)
- B. 200 mg/dL (11.42 mmol/L)
- C. 250 mg/dL (14.28 mmol/L)
- D. 350 mg/dL (20.0 mmol/L)
Correct Answer: C
Rationale: The normal blood glucose level ranges from 70 to 110 mg/dL (4 to 6 mmol/L), or as designated and preferred by the primary health care provider. The client with diabetes mellitus should be taught to report blood glucose levels that exceed 250 mg/dL (14.28 mmol/L), unless otherwise instructed by the primary health care provider. Options 1 and 2 are high levels but do not require primary health care provider notification. Option 4 is a high value; the client should report an elevated level before it reaches this point.
A nurse is preparing to talk about hormone replacement therapy (HRT) to a group of women at a women's fair at the local hospital. Which statements regarding HRT are correct? Select all that apply.
- A. HRT decreases the risk of breast cancer.
- B. HRT decreases the risk of stroke in postmenopausal women.
- C. HRT lowers the risk of bone fractures caused by osteoporosis.
- D. HRT increases the risk of bone fractures caused by osteoporosis.
- E. HRT decreases the risk of coronary artery disease (CAD) in women who do not smoke.
Correct Answer: C
Rationale: HRT reduces fracture risk by improving bone density. It increases breast cancer, stroke, and CAD risks, and does not decrease CAD risk in non-smokers.
A client has received a prescription for lisinopril. The nurse teaches the client that which frequent side effect may occur?
- A. Cough
- B. Polyuria
- C. Hypothermia
- D. Hypertension
Correct Answer: A
Rationale: Cough is a frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors. Fever is an occasional side effect. Proteinuria is another common side effect, but polyuria is not. Hypertension is the reason to administer the medication rather than a side effect.