Nokea
Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse?
- A. I put a night-light in my mother’s bedroom.
- B. I got carbon monoxide detectors for my mother’s house.
- C. I changed my mother’s furniture around.
- D. I got my mother large-print books.
Correct Answer: C
Rationale: Changing furniture increases fall risk in an elderly client with potential sensory deficits, requiring intervention. Night-lights, CO detectors, and large-print books enhance safety.
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The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report?
- A. Loss of peripheral vision.
- B. Floating spots in the vision.
- C. A yellow haze around everything.
- D. A curtain coming across vision.
Correct Answer: A
Rationale: Glaucoma causes loss of peripheral vision due to optic nerve damage from increased intraocular pressure. Floaters suggest vitreous issues, yellow haze is unrelated, and a curtain indicates retinal detachment.
The nurse is planning the care of the client with Meniere's disease. With which member of the interdisciplinary team should the nurse expect a consultation?
- A. Rheumatologist
- B. Otolaryngologist
- C. Physical therapist
- D. Oncologist
Correct Answer: B
Rationale: Since Meniere's disease is a condition of the ear, the nurse would plan to include the otolaryngologist. Rheumatologists, physical therapists, and oncologists treat unrelated conditions.
The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.
The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching?
- A. I should use magnification devices as much as possible.
- B. I will look at my Amsler grid at least twice a week.
- C. I need to use low-watt light bulbs in my house.
- D. I am going to contact a low-vision center to evaluate my home.
Correct Answer: C
Rationale: Low-watt bulbs reduce visibility, counterproductive in macular degeneration. Magnification, Amsler grid monitoring (daily preferred), and low-vision centers are appropriate.
An adult client is admitted for removal of a cataract from her right eye. Which of the following would the client likely have experienced as a result of the cataracts?
- A. Acute eye pain
- B. Redness and constant itching of the right eye
- C. Gradual blurring of vision
- D. Severe headaches and dizziness
Correct Answer: C
Rationale: Cataracts cause gradual blurring of vision due to lens opacity, not acute pain, itching, or headaches.