Nokea
Which nursing intervention is most appropriate to include in the care plan of an anxious client who is blind or has the eyes patched?
- A. Touch the client before speaking.
- B. Explain what you plan to do beforehand.
- C. Stand in front of the client when speaking.
- D. Leave the room lights on at all times.
Correct Answer: B
Rationale: Explaining actions beforehand reduces anxiety by preparing the client for what to expect.
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When describing the examination procedure to the client, which statement by the nurse is most accurate?
- A. You'll read words that are the size of newsprint.
- B. You'll read letters from a distance of 20 feet to mears.
- C. You'll look at a color picture and identify an image.
- D. You'll look at a screen and tell me when an object appears.
Correct Answer: B
Rationale: The Snellen chart involves reading letters from 20 feet to assess visual acuity.
The nurse is caring for the client with psoriasis taking methotrexate. Which laboratory tests are most important for the nurse to monitor? Select all that apply.
- A. Serum potassium level
- B. Liver function tests
- C. Serum glucose level
- D. Arterial blood gases
- E. White blood cells
Correct Answer: B,E
Rationale: The nurse should monitor liver function tests because methotrexate (Trexall) is metabolized by the liver, and a side effect is hepatotoxicity. The nurse should monitor WBCs because a side effect of methotrexate use is leukopenia. Methotrexate has no effect on serum potassium unless complications arise. Glucose monitoring is needed only if the client is diabetic. ABGs are not prescribed for routine monitoring.
The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
- B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
- C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
- D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Correct Answer: B
Rationale: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
Which statement by the nurse most accurately explains the pathophysiology of conductive hearing loss?
- A. Sound waves do not travel to the inner ear.
- B. There is a malfunction of inner ear structures.
- C. The auditory nerve does not transmit sound to the brain.
Correct Answer: A
Rationale: Conductive hearing loss occurs when sound waves are blocked from reaching the inner ear.
The nurse compares the characteristics of open-angle glaucoma with those of angle-closure glaucoma. Which of the following statements describe ways they are similar? Select all that apply.
- A. The visual field examination demonstrates a loss of vision.
- B. Clients are initially treated with medications.
- C. Blurred vision is a common manifestation.
- D. Attacks are self-limited but are more harmful with each episode.
- E. Surgery is often required.
Correct Answer: A,B,E
Rationale: Both types cause vision loss, are initially treated with medications, and may require surgery.