Nokea
The physician has ordered mannitol IV for a client with a head injury. What should the nurse closely monitor because the client is receiving mannitol?
- A. Deep tendon reflexes
- B. Urine output
- C. Level of orientation
- D. Pulse rate
Correct Answer: B
Rationale: Mannitol is a diuretic, so monitoring urine output is critical to assess its effectiveness and prevent dehydration.
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Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply.
- A. The client reports hearing voices in his head.
- B. The client becomes irritable very easily.
- C. The client has difficulty making decisions.
- D. The client’s wife reports he ignores her.
- E. The client does not dominate a conversation.
Correct Answer: B,D,E
Rationale: Irritability, ignoring others, and not dominating conversations suggest hearing loss due to social withdrawal or misunderstanding. Hearing voices is psychiatric, and decision-making is unrelated.
The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report?
- A. Loss of peripheral vision.
- B. Floating spots in the vision.
- C. A yellow haze around everything.
- D. A curtain coming across vision.
Correct Answer: A
Rationale: Glaucoma causes loss of peripheral vision due to optic nerve damage from increased intraocular pressure. Floaters suggest vitreous issues, yellow haze is unrelated, and a curtain indicates retinal detachment.
The nurse is concerned that the Caucasian client experiencing a stroke may have impaired hearing. Which observations of the client's behavior prompted this concern? Select all that apply.
- A. Nods and agrees to all statements made by the nurse
- B. Asks for more information about the therapy schedule
- C. Slow to respond verbally but answers questions appropriately
- D. Speaks in an excessively loud tone of voice
- E. Leans in toward the nurse when the nurse speaks
Correct Answer: A,D,E
Rationale: Nodding and agreeing to all statements, speaking loudly, and leaning toward the speaker suggest hearing impairment. Asking for schedule details and slow but appropriate responses do not indicate hearing issues.
The elderly male client tells the nurse, 'My wife says her cooking hasn't changed, but it is bland and tasteless.' Which response by the nurse is most appropriate?
- A. Would you like me to talk to your wife about her cooking?
- B. Taste buds change with age, which may be why the food seems bland.
- C. This happens because the medications sometimes cause a change in taste.
- D. Why don't you barbecue food on a grill if you don't like your wife's cooking?
Correct Answer: B
Rationale: Age-related taste bud decline reduces taste perception, a common issue in the elderly. Talking to the wife, blaming medications, or suggesting grilling are less appropriate.
The nurse reviews the chart of the client diagnosed with closed-angle glaucoma. Which documented finding should the nurse question with the HCP?
- A. Sudden onset of eye pain
- B. Reduced central visual acuity
- C. Normal intraocular pressure
- D. Nausea and vomiting
Correct Answer: C
Rationale: Closed-angle glaucoma causes an increased, not normal, intraocular pressure. This documentation finding should be questioned. Sudden eye pain, reduced central visual acuity, and nausea and vomiting are consistent with closed-angle glaucoma.