Nokea
Which comment made to the nurse strongly suggests that the client with glaucoma needs more teaching?
- A. I must wash my hands before instilling the dress.
- B. This drug decreases the formation of fluid in my eye.
- C. I'll need to take this until my eye pressure is normal.
- D. The cap on the container should be replaced after use.
Correct Answer: C
Rationale: Glaucoma requires lifelong treatment, not just until pressure normalizes.
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After cataract surgery, the client tells the nurse of severe pain in the operative eye. Which nursing action is most appropriate?
- A. Report the finding to the charge nurse.
- B. Give the client a prescribed analgesic.
- C. Assess the client's pupil response with a penlight.
- D. Reposition the client on the operative side.
Correct Answer: A
Rationale: Severe pain may indicate complications, requiring immediate reporting to the charge nurse.
The nurse is assessing the client. Which findings should the nurse associate with herpes zoster?
- A. Serous drainage and pus
- B. Nodular lesions and burning
- C. Painful vesicles and pruritus
- D. Macule lesions and petechiae
Correct Answer: C
Rationale: The nurse should associate pain and pruritus (itching) with herpes zoster. Herpes zoster follows the path of peripheral sensory nerves; symptoms come from the nerve involvement. Serous drainage and pus indicate infection of vesicles. Nodular lesions are not associated, though burning may occur. Macule lesions may occur early, but petechiae are not associated.
The nurse is caring for the client who is diagnosed with a carbuncle. Which home measures should the nurse discuss? Select all that apply.
- A. Leave the draining lesion open to the air so it dries.
- B. Use strict hand washing to prevent cross-contamination.
- C. Cover the mattress and pillows with plastic covers.
- D. Apply ice to the affected area 20 minutes twice daily.
- E. Wash all linens, towels, and clothing after each use.
- F. Remove all throw rugs to prevent tripping or falls.
Correct Answer: B,C,E
Rationale: Treatments for an infected lesion should include strict hand washing to prevent cross-contamination. Covering mattress and pillows with plastic covers and washing all linens, towels, and clothing after each use will prevent cross-contamination. Leaving the lesion open to air is not advised; a dressing is needed. Applying ice or removing throw rugs does not pertain to carbuncle treatment.
The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is 'tired of it all.' Which is the nurse’s best therapeutic response?
- A. These wounds can heal if we get enough protein into you.'
- B. Are you tired of the treatments and needing to be cared for?'
- C. Why would you say that? We are doing our best.'
- D. Have you made out an advance directive to let the HCP know your wishes?'
Correct Answer: B
Rationale: Reflecting the client’s feelings encourages discussion, addressing emotional distress. Protein focus, defensiveness, or advance directives dismiss the client’s emotions.
The 55-year-old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox?
- A. Deep vein thrombosis.
- B. Varicella pneumonia.
- C. Pericarditis.
- D. Scarring of the skin.
Correct Answer: B
Rationale: Varicella pneumonia is a serious complication in adults with chickenpox, especially older adults. DVT, pericarditis, and scarring are less common.