Nokea
Which symptom related to the chronic progression of untreated glaucoma will a client most likely report to the nurse?
- A. Tunnel vision
- B. Double vision
- C. Bulging eyes
- D. Bloodshot eyes
Correct Answer: A
Rationale: Untreated glaucoma leads to tunnel vision due to progressive peripheral vision loss.
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Which plan best promotes a blind client's feeling of self-reliance when eating?
- A. Help the client locate food by comparing its placement to clock positions.
- B. Ask a hospital volunteer to feed the client so the client does not have to ask for help.
- C. Order foods that can be sipped from containers rather than eaten with utensils.
- D. Ask the dietary department to serve the client's food on paper plates and in cups.
Correct Answer: A
Rationale: Using clock positions empowers the client to eat independently by orienting them to food placement.
Which standing nursing order should be eliminated from this client's care plan?
- A. Keep the client's bed in a low position at all times.
- B. Urge the client to cough every 2 hours while awake.
- C. Assist the client when ambulating in the hall or room.
Correct Answer: B
Rationale: Coughing is unnecessary and may increase intraocular pressure, risking complications.
When assessing the client's skin the nurse notices a rounded area of hair loss with redness, pustules, and scales that appear greenish-yellow when exposed to a black light (Wood's lamp). The nurse should plan to implement treatment for which condition?
- A. Lyme disease
- B. Fungal infection
- C. Anaerobic infection
- D. Contact dermatitis
Correct Answer: B
Rationale: A fungal infection that manifests on the scalp with red, scaly lesions and hair loss will appear either greenish-yellow or bluish-green under a Wood's lamp. Lyme disease produces a bull's-eye rash that does not fluoresce. Anaerobic infections have diffuse redness and do not fluoresce. Contact dermatitis does not display a discrete, rounded area of hair loss or fluoresce.
Which action is the nurse's immediate priority?
- A. Rub petroleum jelly into the burned areas.
- B. Wrap the affected areas with a clean cloth.
- C. Apply cool water to the burns.
- D. Roll the victim to smother the flames.
Correct Answer: D
Rationale: Smothering flames stops the burning process, the immediate priority.
Of the following information provided by the client to the nurse, which factor is most likely to cause a retinal detachment?
- A. The client is younger than age 40.
- B. The client fell and struck the head.
- C. The client has multiple allergies.
- D. The client is being treated for glaucoma.
Correct Answer: B
Rationale: Trauma, such as a head injury, is a common cause of retinal detachment.