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What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?
- A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
- B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
- C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
- D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
Correct Answer: C
Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.
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During an interview with a client planning elective surgery, the client asks the nurse, 'What is the advantage of having a preferred provider organization insurance plan?' Which response is best for the nurse to provide?
- A. Neither plan allows the selection of healthcare providers or hospitals.
- B. There are fewer healthcare providers to choose from than in an HMO plan.
- C. An individual may select healthcare providers from outside of the PPO network.
- D. An individual can become a member of a PPO without belonging to a group.
Correct Answer: C
Rationale: The best response for the nurse to provide is option C, as it highlights a key advantage of a preferred provider organization (PPO) insurance plan. By stating that an individual may select healthcare providers from outside of the PPO network, the nurse emphasizes the flexibility and freedom of choice that PPO plans offer. This feature allows individuals to seek care from providers who are not part of the PPO network, albeit at a higher cost. Option A is incorrect because both PPO and HMO plans allow the selection of healthcare providers, although with different restrictions. Option B is incorrect as PPO plans typically offer a larger selection of healthcare providers compared to HMO plans. Option D is incorrect as membership in a PPO usually requires affiliation with a group, such as through employment or membership in an organization.
A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?
- A. Lymph node involvement is not significant.
- B. Small tumors are aggressive and indicate poor prognosis.
- C. The tumor's estrogen receptor guides treatment options.
- D. Stage I indicates metastasis.
Correct Answer: C
Rationale: Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer.
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, 'The client will verbalize symptoms of pacemaker failure.' Which symptoms are most important to teach the client?
- A. Facial flushing.
- B. Fever.
- C. Pounding headache.
- D. Feelings of dizziness.
Correct Answer: D
Rationale: The correct answer is 'D: Feelings of dizziness.' Feelings of dizziness may occur as a result of a decreased heart rate, leading to decreased cardiac output, which can be an indication of pacemaker failure. Teaching the client to recognize symptoms of decreased cardiac output, like dizziness, is crucial for early detection of pacemaker malfunction. Choices A, B, and C are less specific to pacemaker failure and are not commonly associated with this condition. Facial flushing, fever, and pounding headache are not typical signs of pacemaker failure and are not directly related to cardiac output, making them less relevant for teaching the client about pacemaker failure.
Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?
- A. Place HIV-positive clients in strict isolation and limit visitors.
- B. Wear gloves when coming in contact with the blood or body fluids of any client.
- C. Conduct mandatory HIV testing of those who work with clients with AIDS.
- D. Freeze HIV blood specimens at -70°F to kill the virus.
Correct Answer: B
Rationale: The correct answer is B. The CDC guidelines recommend that healthcare workers wear gloves when coming in contact with blood or body fluids from any client since HIV can be infectious before the client becomes aware of their exposure and/or symptomatic. Choice A is incorrect because placing HIV-positive clients in strict isolation and limiting visitors is not a standard practice for HIV infection control. Choice C is incorrect as mandatory HIV testing for those working with AIDS clients is not a CDC recommendation for routine infection control. Choice D is incorrect because freezing HIV blood specimens at -70°F does not kill the virus; HIV can remain infectious even at very low temperatures.
What most likely led to the 67-year-old woman who lives alone tripping on a rug in her home and fracturing her hip?
- A. Failing eyesight causing an unsafe environment.
- B. Renal osteodystrophy due to chronic renal failure.
- C. Osteoporosis due to hormonal changes.
- D. Cardiovascular changes leading to small strokes impairing mental acuity.
Correct Answer: C
Rationale: The correct answer is C. Osteoporosis, caused by hormonal changes in later life, is the most likely predisposing factor for the fracture in the proximal end of her femur. Osteoporosis leads to reduced bone density, making bones more fragile and susceptible to fractures, especially in the elderly. Choices A, B, and D are less likely to directly lead to a hip fracture in this scenario. Failing eyesight (choice A) could contribute to the fall but is not the main predisposing factor for the fracture. Renal osteodystrophy (choice B) and cardiovascular changes (choice D) are less commonly associated with hip fractures compared to osteoporosis in elderly women.