Nokea
Which statement made to the nurse is the best evidence that the client understands the anticipated outcome of this procedure?
- A. I'm better night vision.
- B. I'll correctly identify colors.
- C. I'll see well without glasses.
- D. I'll use both eyes when reading.
Correct Answer: C
Rationale: LASIK corrects refractive errors, reducing the need for glasses.
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The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma?
- A. The lesion is asymmetrical and has irregular borders.
- B. The lesion has a waxy appearance with pearlike borders.
- C. The lesion has a thickened and scaly appearance.
- D. The lesion appeared as a thickened area after an injury.
Correct Answer: A
Rationale: Asymmetry and irregular borders (ABCD criteria) characterize malignant melanoma. Waxy, scaly, or post-injury lesions suggest other conditions.
Which instruction to the nursing assistant is best for maintaining the client's safety and security?
- A. Let the client take your arm while walking.
- B. Take the client's arm while walking.
- C. You'll see the client in front of you and to your side.
- D. Have the client walk independently by your side.
Correct Answer: A
Rationale: Allowing the client to hold the assistant's arm provides stability and safety.
The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel?
- A. Measure and document the client’s skin lesions.
- B. Apply the antihistamine cream to the lesions.
- C. Set up the isolation equipment for the client.
- D. Determine if the client has prepared an advance directive.
Correct Answer: C
Rationale: Setting up isolation equipment is within UAP scope. Measuring lesions, applying medication, and assessing advance directives require nursing judgment.
A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason?
- A. A longer period of time is too tiring.
- B. Eschar becomes difficult to remove with longer soaking.
- C. Prolonged soaking causes electrolyte dilution.
- D. The water becomes too cool and may cause chilling.
Correct Answer: C
Rationale: Prolonged soaking in the Hubbard tank can lead to electrolyte dilution, risking imbalances in burn clients who are already prone to fluid and electrolyte shifts.
The nurse is most accurate in stating that the cause of Meniere's disease is unknown but that the symptoms are related to which disorder?
- A. A non-suppurative inflammation
- B. A disturbance in the balance of inner ear fluid
- C. An infection in the middle ear
- D. An autoimmune response in the cochlea
Correct Answer: B
Rationale: Meniere's symptoms stem from inner ear fluid imbalance.