Nokea
When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of 'visual sensory/perceptual alterations.' This problem is based on which etiology?
- A. Blurred distance vision
- B. Limited eye movement
- C. Decreased peripheral vision
- D. Photosensitivity
Correct Answer: C
Rationale: The correct answer is 'C: Decreased peripheral vision.' Open-angle glaucoma leads to a gradual loss of peripheral vision due to damage to the optic nerve. This loss of peripheral vision is a hallmark sign of the condition and a primary reason for the visual sensory/perceptual alterations experienced by the client. Blurred distance vision (choice A) may occur but is not the priority nursing problem. Limited eye movement (choice B) and photosensitivity (choice D) are not typically associated with the sensory/perceptual alterations seen in open-angle glaucoma.
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When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Competent venous valves.
- B. Decreased blood volume.
- C. Increase in muscular activity.
- D. Increased venous pressure.
Correct Answer: D
Rationale: The correct answer is 'Increased venous pressure.' In peripheral vascular disease (PVD), impaired blood flow leads to increased venous pressure in the lower extremities, causing fluid to leak out of the blood vessels and accumulate as edema. Choice A, 'Competent venous valves,' is incorrect because in PVD, the venous valves may be incompetent, contributing to venous pooling and edema. Choice B, 'Decreased blood volume,' is incorrect as PVD is associated with impaired blood flow rather than reduced blood volume. Choice C, 'Increase in muscular activity,' is incorrect as it does not directly relate to the development of edema in PVD.
A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?
- A. Call the clinic if undesirable side effects of medications occur
- B. Avoid crowded enclosed areas to reduce pathogen exposure
- C. Increase the daily intake of oral fluids to liquefy secretions
- D. Teach anxiety reduction methods for feelings of suffocation
Correct Answer: C
Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively. Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.
A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.
In a patient with liver cirrhosis, which of the following lab results would be expected?
- A. Increased bilirubin levels.
- B. Decreased albumin levels.
- C. Increased liver enzymes.
- D. Decreased platelet count.
Correct Answer: A
Rationale: In a patient with liver cirrhosis, increased bilirubin levels would be expected. Liver cirrhosis leads to impaired liver function, causing a decrease in the liver's ability to process bilirubin, leading to its accumulation in the blood. This results in elevated bilirubin levels. Decreased albumin levels (choice B) may occur in liver cirrhosis due to impaired liver synthesis of proteins, but it is not as specific as increased bilirubin levels. Increased liver enzymes (choice C) can be seen in liver damage but are not as characteristic as elevated bilirubin levels. Decreased platelet count (choice D) can occur in liver cirrhosis due to hypersplenism, but it is not as specific as increased bilirubin levels in this context.
To reduce the risk of pulmonary complications for a client with ALS, which intervention should the nurse implement?
- A. Perform chest physiotherapy
- B. Teach the client breathing exercises
- C. Initiate passive range of motion exercises
- D. Establish a regular bladder routine
Correct Answer: A
Rationale: Performing chest physiotherapy is the most appropriate intervention to reduce the risk of pulmonary complications in clients with ALS. Chest physiotherapy helps mobilize and clear respiratory secretions, improving lung function and reducing the risk of complications such as pneumonia. Teaching breathing exercises (Choice B) may be beneficial for some clients, but chest physiotherapy is more specifically targeted at managing pulmonary issues in ALS. Initiating passive range of motion exercises (Choice C) and establishing a regular bladder routine (Choice D) are important interventions in ALS care but are not directly related to reducing the risk of pulmonary complications.