Nokea
The nurse notices a new area of skin breakdown near the site of a dressing. This
would be an example of which phase of the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale:
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A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?
- A. Once retinal detachment occurs, it does not return to its normal state
- B. Once the tissue has necrosed from high-pressure, it does not regenerate
- C. Glaucoma always leads to permanent blindness
- D. Once bacterial infection has caused damage, the tissue does not regenerate
Correct Answer: B
Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
A post-operative client with a sutured abdominal incision felt a sharp
abdominal pain after having a bowel movement. Upon inspection, the nurse
notices bowel protruding from the incision site. What does the nurse tell the
physician about the event?
- A. The client's incision site has eviscerated
- B. The client's incision site has lacerated
- C. The client's incisional site is approximated
- D. The client's incisional site has dehisced after.
Correct Answer: A
Rationale:
A client has an open wound with creamy thick yellow drainage. How would the
nurse document this finding?
- A. Purulent
- B. Serosanguinous
- C. Sanguineous
- D. Serous
Correct Answer: A
Rationale:
What is a classic symptom assessed in clients with lupus?
- A. Butterfly rash
- B. Chvostek's sign
- C. Ovid's sign
- D. Heberden's nodes
Correct Answer: A
Rationale:
What is not a potential complication of RA?
- A. Paresthesia's
- B. Fibromyalgia
- C. Joint deformity
- D. Dry eyes
Correct Answer: A
Rationale: