Nokea
The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:
The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:
- A. use any sedatives.
- B. become constipated.
- C. use atropine in any form.
- D. release my emotions by crying.
Correct Answer: C
Rationale: Atropine increases intraocular pressure, worsening glaucoma, indicating correct understanding.
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John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
The level of the water in the water-seal chamber is at
- A. 2 cm
- B. -20 cm
- C. -10 cm
- D. -80 cm
Correct Answer: A
Rationale: The water-seal chamber is maintained at 2 cm to prevent air entry.
The output from a client's indwelling catheter is 500 mL for the past 10 hours. The nurse should:
- A. Do nothing because the output is within normal limits.
- B. Notify the doctor because the output is too low.
- C. Replace the indwelling catheter.
- D. Force fluids to increase the output in the next 8 hours.
Correct Answer: A
Rationale: Urine output of 500 mL in 10 hours (50 mL/hour) is within normal limits (30-50 mL/hour). No intervention is needed.
An adult is admitted to the psychiatric unit with a severe phobia. She develops severe anxiety when she crosses any type of bridge. She can no longer go to work or go shopping at the mall. The day after admission, she develops a panic attack and refuses to go to occupational therapy because she has to cross a bridge-like structure to go from one area of the hospital to another. How should the nurse respond to this situation?
- A. Accompany the client as she goes to occupational therapy
- B. Request that she be excused from occupational therapy until she is less anxious
- C. Have a staff member walk her to occupational therapy by a different route that does not cross a bridge-like structure
- D. Tell her that facing her fears is the only way to conquer them and that the nurse will help her do that
Correct Answer: C
Rationale: Using an alternate route avoids triggering the phobia, allowing participation in therapy while respecting her current anxiety level.
As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
- A. Decreased appetite
- B. Inadequate fluid intake
- C. Prolonged gastric emptying
- D. Reduced intestinal motility
Correct Answer: D
Rationale: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.
You're filling in as a substitute school nurse. When an 11-year-old child with an earache and sore throat reports to the nurse's office, you inspect the tympanic membrane using an otoscope.
Which color suggests a normal eardrum?
- A. Red
- B. White
- C. Gray
- D. Yellowish
Correct Answer: C
Rationale: A normal eardrum appears pearly gray.