Nokea
Which statement about glaucoma is true and accurate?
- A. Acute angle-closure glaucoma is an ocular emergency.
- B. Acute angle-closure glaucoma leads to the loss of peripheral vision and tunnel vision.
- C. Primary open-angle glaucoma leads to eye pain, nausea, and vomiting, blurry vision, and halos.
- D. Bubbles are implanted to protect the retina from glaucoma.
Correct Answer: A
Rationale: The correct answer is A: 'Acute angle-closure glaucoma is an ocular emergency.' Acute angle-closure glaucoma is indeed considered an ocular emergency that requires immediate attention to prevent vision loss. Choice B is incorrect because acute angle-closure glaucoma commonly presents with symptoms like severe eye pain, headache, blurred vision, and halos around lights. Choice C is incorrect as these symptoms are more indicative of acute angle-closure glaucoma rather than primary open-angle glaucoma. Choice D is incorrect since bubbles are not typically used to protect the retina from glaucoma; treatment usually involves medications, laser therapy, or surgery to manage intraocular pressure.
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Which healthcare-associated infection poses the greatest risk for patients?
- A. Pneumonia
- B. Catheter-related infections
- C. Intravenous line infections
- D. C. difficile
Correct Answer: B
Rationale: Catheter-related infections pose the greatest risk for patients in healthcare settings. Catheters are invasive devices that can introduce pathogens directly into the bloodstream, leading to severe infections. Pneumonia, intravenous line infections, and C. difficile infections are serious concerns as well, but catheter-related infections are particularly risky due to the direct access they provide for pathogens to enter the body.
A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?
- A. Keep the client in their room with the door closed
- B. Contact a family member to come and sit with the client
- C. Place the client in a wheelchair with a lap tray
- D. Administer a sedative to the client
Correct Answer: B
Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.
A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
- A. File an incident report.
- B. Ask the client about his injuries with the son present.
- C. Ask the client's son to go to the waiting area.
- D. Treat and discharge the client
Correct Answer: C
Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.
Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?
- A. The client will be very thirsty.
- B. The client will complain of nausea.
- C. The client will need to urinate.
- D. The client will have moist skin.
Correct Answer: D
Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.
Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?
- A. Headache and muscle cramps
- B. Dyspnea and respiratory crackles
- C. Increased pulse rate and blood pressure
- D. Orthostatic hypotension and flat neck veins
Correct Answer: D
Rationale: Orthostatic hypotension and flat neck veins are classic manifestations of fluid volume deficit. When the body loses fluid, blood volume decreases, leading to decreased venous return to the heart, resulting in orthostatic hypotension and flat neck veins. Choices A, B, and C are more indicative of other conditions such as dehydration, respiratory issues, or compensatory mechanisms in response to hypovolemia, respectively.