Nokea
The nurse should assess an older adult with macular degeneration for:
- A. Loss of central vision.
- B. Loss of peripheral vision.
- C. Total blindness.
- D. Blurring of vision.
Correct Answer: A
Rationale: Macular degeneration primarily affects the macula, leading to loss of central vision, which impairs activities like reading and recognizing faces.
You may also like to solve these questions
After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The rationale that supports applying pressure is that it:
- A. Prevents the medication from entering the tear duct.
- B. Prevents the drug from running down the client's face.
- C. Allows the sensitive cornea to adjust to the medication.
- D. Facilitates distribution of the medication over the eye surface.
Correct Answer: A
Rationale: Applying pressure at the inner canthus (punctal occlusion) prevents the medication from draining into the tear duct, which could lead to systemic absorption or reduced effectiveness of the eye drops.
When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
- A. Apples.
- B. Tomato juice.
- C. Whole wheat bread.
- D. Beef tenderloin.
Correct Answer: B
Rationale: Tomato juice is high in sodium, which should be limited on a 2-g sodium diet to prevent fluid retention in heart failure.
What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following?
- A. External hemorrhage.
- B. Decreasing level of consciousness.
- C. Laryngeal nerve damage.
- D. Upper airway obstruction.
Correct Answer: C
Rationale: Asking the client to speak monitors for laryngeal nerve damage, which can cause vocal cord paralysis and hoarseness, a potential complication of thyroidectomy.