Nokea
What images will a client with macular degeneration most likely describe seeing?
- A. Objects that are close to the face
- B. Objects that are clear distance
- C. Objects that are in outer peripheral fields
- D. Objects that are in the central field of vision
Correct Answer: C
Rationale: Macular degeneration spares peripheral vision, affecting central vision.
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The client is scheduled for application of a cadaver homograph to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?
- A. The graft donor site from my right upper thigh shouldn't take too long to heal.
- B. I know this graft will only be a temporary measure to protect and help heal my arm.
- C. I am glad that there is no risk of me getting a blood-borne disease with this type of graft.
- D. If this graft doesn't permanently take, then I'll need to select another graft donor site.
Correct Answer: B
Rationale: A cadaver skin graft is a type of temporary graft, also called a biological dressing, and it is used to protect the damaged skin and promote healing and epithelialization. A cadaver skin graft does not use the client's own skin, so there is no donor site. There is a risk of transmitting blood-borne infections with cadaver grafts. The graft is not permanent, so no further donor site selection is needed.
When developing nursing care plans, the nurse is careful to classify which type of wound as a chronic wound?
- A. A gunshot wound with tissue damage
- B. A slow-healing diabetic foot ulcer
- C. A stage I pressure ulcer on the coccyx
- D. A 7-day-old infected surgical wound
Correct Answer: B
Rationale: Diabetic foot ulcers heal slowly, classifying them as chronic.
Which assessment finding is commonly noted when the intraocular pressure (IOP) of a client with angle-closure glaucoma becomes dangerously high?
- A. Spots in the visual field
- B. Severe eye pain
- C. Pinpoint pupils
- D. Bulging eyes
Correct Answer: B
Rationale: Acute angle-closure glaucoma causes severe eye pain due to rapidly elevated IOP.
During the initial assessment, the nurse can assist the physician in determining the etiology of the client's problem by assessing if there is a history of which condition?
- A. Recent nasal injury
- B. Respiratory allergies
- C. Previous nasal surgery
- D. A past tonsillectomy
Correct Answer: B
Rationale: Respiratory allergies are a common cause of nasal polyps.
The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan?
- A. Alteration in comfort.
- B. Altered body image.
- C. Anxiety.
- D. Altered family processes.
Correct Answer: B
Rationale: Psoriasis’s visible plaques often cause body image disturbance. Comfort, anxiety, and family processes are secondary.