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.
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The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.
Which finding of the client's biographical data most likely contributed to developing skin cancer?
- A. The client is a chronic cigarette smoker.
- B. The client has male pattern baldness.
- C. The client works for a drug manufacturer.
- D. The client bathes with a deodorant soap.
Correct Answer: B
Rationale: Baldness increases scalp sun exposure, a risk factor for skin cancer.
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.
After cleaning a client's prescription eyeglasses with soap and warm water or a commercial glass cleaner, which nursing action is best for drying the moist lenses?
- A. Rub the lenses with a paper tissue.
- B. Wipe the lenses with a soft cloth.
- C. But the lenses with a paper towel.
- D. Blow on the lenses to promote air drying.
Correct Answer: B
Rationale: A soft cloth prevents scratches and effectively dries the lenses.
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.
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