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You partially darken a room and ask the client to look straight ahead. You use a penlight and, approaching from the side you shine the light, it constricts. You remove the light and then shine it on the same pupil again. You also observe the response of the other pupil. You would normally find the other pupil doing which of the following things?
- A. not make any change in size
- B. dilate in an oppositional response to the light
- C. first constrict, then dilate larger than the other pupil
- D. constrict in consensual response
Correct Answer: D
Rationale: The other pupil constricts consensually when light hits one, a normal reflex. No change, dilation, or mixed response indicates abnormality. Nurses test this for brain function.
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A client has a new diagnosis of lactose intolerance and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should avoid foods that contain lactose.
- B. You should increase your intake of high-fiber foods.
- C. You should avoid foods that contain gluten.
- D. You should increase your intake of dairy products.
Correct Answer: A
Rationale: The correct statement for the nurse to include in teaching a client with lactose intolerance is to avoid foods that contain lactose. Lactose intolerance results from the body's inability to digest lactose, a sugar found in dairy products. By avoiding foods containing lactose, the client can manage symptoms and prevent complications associated with lactose intolerance. Choices B, C, and D are incorrect. Increasing intake of high-fiber foods (choice B) may be beneficial for general health but is not directly related to lactose intolerance. Avoiding gluten (choice C) is necessary for individuals with celiac disease, not lactose intolerance. Increasing intake of dairy products (choice D) would worsen symptoms in individuals with lactose intolerance due to the lactose content.
Polyhydramnios means amniotic fluid volume more than:
- A. 1000 ml
- B. 1500 ml
- C. 2000 ml
- D. 2500 ml
Correct Answer: C
Rationale: Polyhydramnios is excess amniotic fluid, complicating pregnancy. Normal volume at term is 500-1000 ml. Polyhydramnios is diagnosed above 2000 ml (choice C) via ultrasound (amniotic fluid index >24 cm), often due to fetal anomalies (e.g., esophageal atresia) or maternal diabetes. 1000 ml (choice A) is normal, 1500 ml (choice B) is borderline, and 2500 ml (choice D) exceeds typical thresholds but isn't the standard cutoff. C is correct, per obstetric guidelines. Nurses monitor for preterm labor or distress, supporting maternal-fetal care.
Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
- A. clinical judgment of transition to a higher level of wellness
- B. nursing judgment that in some area no pathology exists
- C. a judgment that in some area there is more wellness than illness
- D. statement of an area of family strength to use in interventions
Correct Answer: A
Rationale: A wellness nursing diagnosis best describes a clinical judgment of transitioning to a higher wellness level, focusing on enhancing health beyond mere absence of disease. Unlike pathology-based diagnoses, it identifies potential for growth like improving nutrition in a healthy client reflecting nursing's preventive role. Judging no pathology or more wellness than illness is narrower, missing the forward-looking aspect, while family strengths support interventions but aren't the diagnosis. This perspective encourages proactive care, aligning with wellness models to elevate client health.
A client with a new diagnosis of celiac disease is being taught about dietary management. Which of the following statements should be included by the healthcare provider?
- A. You should avoid foods that contain gluten.
- B. You should increase your intake of dairy products.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: 'You should avoid foods that contain gluten.' Gluten is a protein found in wheat, barley, and rye, which can trigger an immune response in individuals with celiac disease. Avoiding gluten-containing foods is crucial to managing the condition and preventing symptoms and complications associated with celiac disease. Choices B, C, and D are incorrect. Increasing dairy intake (Choice B) is not necessary for celiac disease management. Avoiding lactose (Choice C) is relevant for individuals with lactose intolerance, not celiac disease. While high-fiber foods (Choice D) are generally beneficial for health, they are not specifically indicated for celiac disease management.
The nurse encouraged Mr. Gary to make his own care decisions. This is an example of?
- A. Empowerment
- B. Advocacy
- C. Coping
- D. Quality improvement
Correct Answer: A
Rationale: Encouraging care decisions is empowerment (A) control to patient, per definition. Advocacy (B) supports, coping (C) manages, QI (D) enhances not decision-specific. A fits patient autonomy, making it correct.