Free Multi Dimensional Care practice for Multi Dimensional Care | Final Exam (ATI RN). Answer 76 nursing exam-style questions with rationales, exam mode, and pr
The following client come to the ophthalmology clinic. Which client needs to be seen first?
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Explanation:
Worsening vision after cataract surgery requires immediate attention to prevent complications.
A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?
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Explanation:
What nursing interventions increase the risk the pressure injuries?
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Explanation:
What is the most common method of reducing and immobilizing a fracture?
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Explanation:
Open reduction with internal fixation (ORIF) is the most common method for reducing and immobilizing fractures.
What medication class can decrease tissue in inflammation but delays bone healing?
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Explanation:
A client is diagnosed with glaucoma. The provider needs to determine if it is open-angle glaucoma or closed-angle glaucoma. What test does the nurse anticipate?
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Explanation:
Gonioscopy is the appropriate test to anticipate in this scenario. It is used to distinguish between open-angle and closed-angle glaucoma by examining the angle where the iris meets the cornea. Choice A, ultrasonic imaging, is not typically used to differentiate between these types of glaucoma. Choice C, corneal staining, is used to detect corneal abrasions and defects, not to differentiate between types of glaucoma. Choice D, electroretinography, is a test that measures the electrical responses of various cell types in the retina and is not specific to differentiating between open-angle and closed-angle glaucoma.
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?
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Explanation:
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.
Why is a client with osteoporosis prone to fractures?
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Explanation:
The correct answer is C. Osteoporosis is characterized by porous, weak bones due to decreased bone density. This porous nature of bones in osteoporosis makes them more prone to fractures. Choice A is incorrect because bone spurs do not lead to fractures in osteoporosis; they are bony outgrowths unrelated to osteoporosis. Choice B is incorrect as osteoporosis is associated with decreased, not increased, bone density. Choice D is incorrect as individuals with osteoporosis are indeed prone to fractures due to weakened bones.
A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?
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Explanation:
Death of bone tissue can occur when the blood supply to the bone is disrupted. What is this complication called?
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Explanation:
The correct answer is B, avascular necrosis. Avascular necrosis is the condition where bone tissue dies due to the disruption of blood supply to the bone. Reflex sympathetic dystrophy (Choice A) is a chronic pain condition, delayed union (Choice C) refers to a delayed healing of a fracture, and complex regional pain syndrome (Choice D) is a chronic pain condition typically affecting an arm or leg.
What is a negative effect of immobility on the musculoskeletal system?
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Explanation:
Contractures are a negative effect of immobility on the musculoskeletal system.
What does CREST stand for?
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Explanation:
The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?
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Explanation:
On inspection, which client does the nurse suspect of having a visual impairment?
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Explanation:
Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.
What may be a cause of conductive hearing loss?
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Explanation:
Otitis media can cause conductive hearing loss by affecting the middle ear.
What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?
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Explanation:
Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.
What may be a cause of conductive hearing loss?
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Explanation:
Otitis media can cause conductive hearing loss by affecting the middle ear.
Which of the following nonpharmacological methods cannot be used to manage the chronic pain of a client with rheumatoid arthritis?
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Explanation:
The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?
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Explanation:
What is accurate health promotion teaching to prevent ear infection or trauma? (Select all that apply)
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Explanation:
The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.
What is the priority nursing diagnosis for a client with immobility?
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Explanation:
The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.
The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?
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Explanation:
Touching the dropper to the eye contaminates it and can lead to infection.
A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?
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Explanation:
What repetitive stress injury is a factory worker at risk of?
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Explanation:
Factory workers are at risk of developing Carpal Tunnel Syndrome due to repetitive hand movements involved in their work. This condition occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. Plantar fasciitis (choice A) is a condition affecting the foot, not typically associated with factory work. Osteomalacia (choice B) is a softening of the bones due to a lack of vitamin D or calcium, not directly related to repetitive stress in factory work. Osteoporosis (choice D) is a condition characterized by weak and brittle bones, usually associated with aging or hormonal changes rather than repetitive stress injuries.
Which test is used in the diagnosis of osteoporosis?
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Explanation:
The correct answer is B, Dual-energy X-ray absorptiometry (DXA) scan, which is commonly used to diagnose osteoporosis by measuring bone mineral density. Phalen's maneuver (choice A) is a test used to assess for carpal tunnel syndrome and is not related to osteoporosis. Proprioception (choice C) refers to the sense of body position and is not a diagnostic test for osteoporosis. Blood culture (choice D) is used to detect infections caused by bacteria in the bloodstream and is not relevant to the diagnosis of osteoporosis.
The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?
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Explanation:
The nurse is caring for 4 clients. What client should the nurse see first?
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Explanation:
The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.
What statement by the client with plantar fasciitis indicates a need for further teaching?
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Explanation:
The correct answer is A. Using warm packs can exacerbate inflammation in plantar fasciitis. Choices B, C, and D are all appropriate interventions for managing plantar fasciitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation. Resting and stretching the feet can promote healing and reduce symptoms. Wearing supportive shoes can provide stability and reduce strain on the plantar fascia. Therefore, the client's statement about using warm packs indicates a need for further teaching as it can worsen the condition.
The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?
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Explanation:
A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.
Which of the following is NOT a risk factor for osteoarthritis?
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Explanation:
What is a negative effect of immobility on the cardiovascular system?
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Explanation:
Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.
A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?
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Explanation:
What device would be best to use for a client who is immobile?
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Explanation:
A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.
Which of the following statements made by a client diagnosed with human immunodefiency virus (HIV) would require further teaching?
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Explanation:
A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client?
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Explanation:
A client with a diagnosis of Human Immunodeficiency Virus develops pneumonia. What type of infection is this?
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Explanation:
The correct answer is A: An opportunistic infection. In patients with Human Immunodeficiency Virus (HIV), infections like pneumonia are considered opportunistic because they take advantage of a weakened immune system. Option B, root cause infection, is incorrect as it does not describe the nature of the infection in relation to the patient's condition. Option C, pathogenic infection, is incorrect because while pneumonia is caused by pathogens, in the context of HIV, it is specifically termed as an opportunistic infection. Option D, nosocomial infection, is also incorrect as it refers to infections acquired in a healthcare setting, not related to the patient's HIV status.
The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which statements would the nurse use to best describe a sentinel event?
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Explanation:
The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has?
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Explanation:
What is a symptom of the expected disease pattern of rheumatoid arthritis?
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Explanation:
What is an example of a client's primary defense to infection?
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Explanation:
A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?
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Explanation:
Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)
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Explanation:
Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.
A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?
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Explanation:
The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.
The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?
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Explanation:
The nurse is caring for 4 clients. Which of these clients will the nurse see first?
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Explanation:
The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.
A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
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Explanation:
The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?
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Explanation:
Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.
The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?
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Explanation:
Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?
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Explanation:
A nurse is caring for an immobile client. What is the priority assessment of this client?
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Explanation:
Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.
A nurse is providing teaching to an older client who has osteoarthritis that is affecting the knees. What statement by the client indicates a correct understanding of the teaching?
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Explanation:
The nurse educates a client about how to reduce their risk for osteoporosis. Which of these statements by the nurse is correct? (Select all that apply)
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Explanation:
Reducing caffeine and alcohol intake, and quitting smoking can help decrease the risk of osteoporosis.
When providing a routine bed bath, what action does the nurse complete first?
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Explanation:
The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?
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Explanation:
In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.
A nurse is teaching a newly hired group of unlicensed assistive personnel about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?
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Explanation:
During a skin inspection at the outpatient clinic, the nurse notices patches of thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect?
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Explanation:
By providing measures to reduce skin breakdown, how does the nurse break the chain of infection?
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Explanation:
What are signs of hearing loss? (Select all that apply)
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Explanation:
Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
Where will the nurse collect the most reliable source of pain assessment?
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Explanation:
The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?
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Explanation:
Which organization publishes the National Patient Safety Goals?
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Explanation:
A client has a new diagnosis of human immunodeficiency virus HIV. The client is distraught and does not know what to do. What intervention by the nurse is the best?
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Explanation:
A client is recovering from a fractured radius that occurred 7weeks ago. Which state of bone healing occurs at this time as the callus is restored and transformed into bone?
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Explanation:
A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?
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Explanation:
The client complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?
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Explanation:
A client has AIDS. Which of these findings indicate possible infection?
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Explanation:
What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmission-based precautions?
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Explanation:
What occurs during stage three of bone healing?
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Explanation:
During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.
The client states, "the doctor says I am nearsighted. I do not get it." What would be the best response by the nurse?
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Explanation:
The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.
What activities should the client avoid after cataract surgery? (Select all that apply)
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Explanation:
After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one's nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.
A client has a fractured right arm. What should the nurse do first?
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Explanation:
The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.
What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?
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Explanation:
The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.
The client states, "the doctor says I am nearsighted. I do not get it." What would be the best response by the nurse?
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Explanation:
The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.
What activities should the client avoid after cataract surgery? (Select all that apply)
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Explanation:
After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one's nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.
A client has a fractured right arm. What should the nurse do first?
Select the best answer.
Explanation:
The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.
What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?
Select the best answer.
Explanation:
The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.
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