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The nurse is talking with a client with macular degeneration. Which of the following statements by the client would be consistent with the condition?
- A. I have been seeing small flashes of light in one eye.
- B. I noticed that my peripheral vision is becoming worse.
- C. I see a blurry spot in the middle of the page when I read.
- D. I cannot see the newspaper unless I hold it away from me.
Correct Answer: C
Rationale: Macular degeneration affects central vision, causing a blurry or dark spot in the visual field, as described in (C), due to damage to the macula. Flashes of light (A) suggest retinal issues, peripheral vision loss (B) is typical of glaucoma, and difficulty reading up close (D) relates to presbyopia.
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A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions should the nurse anticipate for this client? Select all that apply.
- A. Cluster care to limit each staff member's time in the room
- B. Instruct the client to be up and around in the room but not to leave the room
- C. Remind family members and visitors to limit close contact with the client
- D. Use protective shielding, if available, when providing direct client care
- E. Wear a radiation badge while in the client's room to measure radiation exposure
Correct Answer: A,C,D,E
Rationale: Brachytherapy involves internal radiation, requiring precautions to minimize exposure. Clustering care (A) reduces staff exposure time. Limiting visitor contact (C) protects others from radiation. Protective shielding (D) and radiation badges (E) ensure safety and monitor exposure. Ambulation (B) is restricted to prevent dislodging the radiation source.
The office nurse receives 4 telephone messages from clients. Which client does the nurse anticipate as the priority for treatment?
- A. 20-year-old college student who reports a ringlike, red bull’s-eye-shaped, itchy leg rash after hiking in the woods 2 days ago
- B. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching
- C. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago
- D. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well
Correct Answer: C
Rationale: Headaches and gait disturbance in a 78-year-old on warfarin post-fall (C) suggest a possible subdural hematoma, a life-threatening condition requiring immediate evaluation. Bull’s-eye rash (A) suggests Lyme disease, vaginal discharge (B) indicates yeast infection, and diarrhea (D) is a colchicine side effect, all less urgent.
The nurse has reinforced teaching with the parent of a 3-year-old client who has acute diarrhea. Which of the following statements by the parent would require follow-up?
- A. I will apply a skin barrier cream to my child’s diaper area until the diarrhea subsides.
- B. I will encourage my child to drink small amounts of fluids at frequent intervals.
- C. I will feed my child a diet of bananas, rice, applesauce, and toast for the next few days.
- D. I will return to the clinic if I notice a decrease in my child’s urine output.
Correct Answer: C
Rationale: The BRAT diet (C) is outdated and may lack nutrients, risking prolonged recovery. Skin barrier cream (A), frequent fluids (B), and monitoring urine output (D) are appropriate for preventing skin breakdown, dehydration, and detecting complications.
Prior to administering a tube feeding, the nurse obtains 50 mL of aspirant. The nurse should:
- A. Discard the aspirant and begin the tube feeding.
- B. Replace the aspirant and begin the tube feeding.
- C. Discard the aspirant and hold the tube feeding.
- D. Replace the aspirant and hold the tube feeding.
Correct Answer: B
Rationale: Replacing the aspirant prevents fluid/electrolyte loss, and feeding can proceed if pH confirms placement. Discarding aspirant risks dehydration, and holding the feeding is unnecessary unless placement is uncertain.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.