Nokea
When testing visual fields, the nurse is assessing which of the following parts of vision?
- A. Peripheral vision
- B. Distance vision
- C. Near vision
- D. Central vision
Correct Answer: A
Rationale: When testing visual fields, the nurse is assessing the peripheral vision. Peripheral vision refers to the outer area of the visual field, away from the center of gaze. It allows individuals to detect objects, movement, and stimuli in their surroundings without needing to focus directly on them. Testing peripheral vision is important for detecting potential visual field deficits that can impede daily activities and safety, such as driving or navigating crowded spaces. By assessing the peripheral vision, healthcare professionals can identify any limitations or abnormalities that may require further evaluation or intervention.
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Nurse Kara is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: Washing your feet in hot water is not recommended as it can actually worsen diabetic foot conditions. Hot water can lead to burns and damage the skin, especially for individuals with reduced sensation in their feet due to diabetes. It is advised to wash feet in warm water instead, avoiding hot temperatures to prevent injuries and complications. The other options provide important aspects of diabetic foot care such as wearing appropriate shoes, trimming toenails carefully, and being mindful of footwear choices to protect the feet.
What is oral candidiasis (thrush) in the newborn?
- A. Bacterial infection that is life threatening in the neonatal period
- B. Bacterial infection of mucous membranes that responds readily to treatment
- C. Yeastlike fungal infection of mucous membranes that is relatively common
- D. Benign disorder that is transmitted from mother to newborn during the birth process only
Correct Answer: C
Rationale: Oral candidiasis, also known as thrush, is a yeastlike fungal infection of the mucous membranes in the mouth. It is relatively common in newborns, as their immune systems are still developing and can be easily affected by the overgrowth of Candida fungi. Thrush can present as white patches or plaques on the tongue, gums, or inner cheeks. It is important to treat oral thrush to prevent any discomfort for the newborn and potential complications such as difficulty feeding or spreading of the infection.
A 16-year-old discusses his recent diagnosis of lupus with the nurse. Which statement best describes adolescent thinking regarding the future?
- A. Adolescents are preoccupied with the present.
- B. Adolescents are beginning to think abstractly and consider future possibilities.
- C. Adolescents think only in concrete terms.
- D. Adolescents are overly concerned with past events.
Correct Answer: B
Rationale: During adolescence, abstract thinking develops, allowing teens to envision future possibilities.
An adolescent patient, who has pelvic inflammatory disease (PID), inquires about the effects of the disease on their ability to bear children. What is the pediatric nurse's best response?
- A. The occurrence of spontaneous abortion during pregnancy increases with PID.
- B. There is an increased risk for ectopic pregnancy or infertility.
- C. There is an increased risk of placenta previa.
- D. There should be no problems with your ability to conceive.
Correct Answer: B
Rationale: PID can lead to scarring of the fallopian tubes, increasing the risk of ectopic pregnancy or infertility.
Which assessment action will help the nurse determine if the patient with Bell's Palsy is receiving adequate nutrition?
- A. Monitor meal trays
- B. Check twice-weekly weights
- C. Measure intake and output
- D. Assess swallowing reflex
Correct Answer: D
Rationale: By assessing the patient's swallowing reflex, the nurse can determine if the patient is able to swallow food and liquids properly, which is crucial for adequate nutrition intake. Bell's Palsy can affect facial muscles, including those involved in chewing and swallowing. A impaired swallowing reflex can lead to difficulties in eating and drinking, which in turn may affect the patient's nutrition status. Monitoring meal trays (A) may not provide direct information about the patient's ability to swallow, as a patient may not be able to communicate swallowing difficulties. Checking twice-weekly weights (B) may indicate weight changes, but it may not necessarily give insight into nutrition adequacy related to swallowing ability. Measuring intake and output (C) may help track calorie intake and fluid balance, but it may not specifically address swallowing issues that can impact nutrition in a patient with Bell's Palsy. Assessing the swallowing reflex (D) directly addresses the patient's ability to consume food and