Nokea
Which of the following is usually the first symptom of a cataract that the nurse would expect a patient to report during assessment?
- A. Dry eyes
- B. Blurring of vision
- C. Eye pain
- D. Loss of peripheral vision
Correct Answer: B
Rationale: The correct answer is B: Blurring of vision. This is typically the first symptom of a cataract because the clouding of the lens causes light to scatter, leading to blurred vision. Dry eyes (A) and eye pain (C) are not typically associated with cataracts. Loss of peripheral vision (D) is more commonly seen in conditions like glaucoma. In summary, blurring of vision is the hallmark symptom of cataracts due to lens clouding, distinguishing it from other eye conditions.
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A client with lung cancer develops Homer’s when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:
- A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
- B. Chest pain, dyspnea, cough, weight loss, and fever.
- C. Arm and shoulder pain and atrophy of arm and hand muscles both on the affected side.
- D. Hoarseness and dysphagia.
Correct Answer: A
Rationale: The correct answer is A: Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. This is indicative of Horner's syndrome, which occurs due to the disruption of sympathetic nerve supply. Miosis (constricted pupil), ptosis (drooping eyelid), and anhidrosis (lack of sweating) are classic signs of Horner's syndrome. These symptoms occur when the tumor invades the ribs and affects the sympathetic nerve ganglia.
Summary of other choices:
B: Chest pain, dyspnea, cough, weight loss, and fever are more commonly associated with lung cancer but not specific to Horner's syndrome.
C: Arm and shoulder pain and atrophy of arm and hand muscles are not typical signs of Horner's syndrome.
D: Hoarseness and dysphagia are more common symptoms of compression of the recurrent laryngeal nerve, not Horner's syndrome.
Appropriate nursing interventions for J.E. would be
- A. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
- B. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive pressure breathing therapy
- C. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and intermittent positive pressure breathing q2h
- D. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief devices Situation - Mr. Reyes suffered head injuries in a motor vehicle accident
Correct Answer: A
Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.
Another girl was bitten by a poisonous snake. All of the following are true except
- A. The victim of a snake bite should be made to exercise the bitten extremity to hasten circulation
- B. The bite of a poisonous snake is distinguished by two fang marks
- C. Immediate severe pain and swelling distinguished the bite of a poisonous snake
- D. The tourniquet should be tight enough to prevent superficial circulation of blood thus stopping absorption of the poison
Correct Answer: A
Rationale: The correct answer is A because exercising the bitten extremity can increase the spread of the venom. Choice B is correct as poisonous snake bites typically leave two fang marks. Choice C is correct as immediate severe pain and swelling are common symptoms of a poisonous snake bite. Choice D is incorrect as a tourniquet should not be used for snake bites as it can lead to complications such as tissue damage and increased risk of infection.
The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. “It will raise you BP, which is necessary because of blood loss.”
- B. “It will dilate your bronchioles and make your breathing easier.”
- C. “It will help your blood to clot to reduce bleeding.”
- D. “It will constrict your vessels and slow down the bleeding.”
Correct Answer: D
Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.
A client has a serum calcium level of 7.2mg/dl. During the physical examination, the nurse expects to assess:
- A. Trousseau’s sign
- B. Hegar’s sign
- C. Homan’s sign
- D. Goodell’s sign
Correct Answer: A
Rationale: The correct answer is A: Trousseau's sign. A serum calcium level of 7.2mg/dl indicates hypocalcemia. Trousseau's sign is a clinical manifestation of hypocalcemia, characterized by carpal spasm induced by inflating a blood pressure cuff above systolic pressure. This occurs due to increased neuromuscular excitability from low calcium levels. Hegar's sign (B) is associated with pregnancy, Homan's sign (C) is a clinical test for deep vein thrombosis, and Goodell's sign (D) is a softening of the cervix during pregnancy. These signs are not relevant to a client with hypocalcemia.