Nokea
While completing a health history the client reports experiencing blurring of vision in both eyes without associated pain. What condition does the nurse suspect?
- A. Macular degeneration
- B. Cataract
- C. Retinal detachment
- D. Glaucoma
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?
- A. Two-point gait
- B. Three-point gait
- C. Four-point gait
- D. Unaffected gait
Correct Answer: B
Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.
Which of the following assessments is found in neurovascular compromise?
- A. Tingling
- B. Strong pulses
- C. Warm skin
- D. Full range motion
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What evaluation indicates successful progress on the client goal of increasing daily physical activity?
- A. The client reports decreased social interaction
- B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
- C. The client reports a fall
- D. The client reports less fatigue walking up stairs
Correct Answer: D
Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.
Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?
- A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
- B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
- C. The UAP carefully empties the indwelling catheter bag
- D. The UAP shows the client how to use the call light
Correct Answer: A
Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.
What is an example of proper body mechanics when lifting?
- A. Lifting the object with your back
- B. Standing with a narrow stance
- C. Lifting excessive weight to strengthen the muscles
- D. Holding the object close to the body
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.