Nokea
Which of the following terms would the eye clinic nurse use to document that a client has nearsightedness?
- A. Presbyopia
- B. Amblyopia
- C. Hyperopia
- D. Myopia
Correct Answer: D
Rationale: Myopia is the medical term for nearsightedness, where distant objects appear blurry.
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The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
- A. Use a pillow to keep the heels off the bed when supine.
- B. Order a low air-loss therapy bed immediately.
- C. Prepare to insert a nasogastric feeding tube.
- D. Order an occupational therapy consult for strength training.
Correct Answer: A
Rationale: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.
The female client calls the clinic and tells the nurse that she has a really big 'boil' in the perineal area that is causing a lot of pain. Which intervention should the nurse implement?
- A. Schedule an emergency appointment for the client.
- B. Instruct the client to apply warm, moist compresses to the area.
- C. Determine if someone can squeeze the boil.
- D. Explain that this will resolve on its own.
Correct Answer: B
Rationale: Warm, moist compresses promote drainage and pain relief in a boil (furuncle). Emergency visits may be needed later, squeezing risks infection, and spontaneous resolution is unlikely.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
- A. The client is complaining of severe pain.
- B. The client’s pulse oximeter reading is 95%.
- C. The client has T 100.4°F, P 100, R 24, and BP 102/60.
- D. The client’s urinary output is 50 mL in two (2) hours.
Correct Answer: C
Rationale: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately?
- A. A small mole on the right thigh that has looked the same ever since the client can remember
- B. A pigmented area that is pink-red in color and has been present since birth
- C. Three small warts on the right hand that have been present for some time
- D. A black and purple mole that is growing larger and has a funny shape
Correct Answer: D
Rationale: A growing, irregularly shaped, and discolored mole may indicate melanoma, requiring immediate medical evaluation.
Which signs and symptoms indicate that the nursing assistant has had an allergic reaction to the latex gloves? Select all that apply.
- A. Raised areas and blisters on the hands
- B. Itchy, red, watery eyes
- C. Nausea and vomiting
- D. Hives
- E. Chest tightness
Correct Answer: A,B,D,E
Rationale: These symptoms indicate a latex allergy, ranging from local to systemic reactions.