Nursing Elites

1. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

• A. Once bacterial infection has caused damage, the tissue does not regenerate.
• B. Once retinal detachment occurs, it does not return to its normal state.
• C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
• D. Glaucoma always leads to permanent blindness.

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

2. 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?

• A. The pain will go away after the swelling decreases.
• B. That is phantom limb pain.
• C. Your foot has been amputated, so you are not having pain in that foot.
• D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: 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.

3. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

• A. Exophthalmos
• B. Anisocoria
• C. Strabismus
• D. Scleral edema

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

4. The nurse is caring for 4 clients. What client should the nurse see first?

• A. A client with multiple children visiting
• B. A client with lupus asking for dinner
• C. A client on Methotrexate with a fever
• D. A client with chronic rheumatic pain

Correct answer: C

Rationale: 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.

5. 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?

• A. Stage 3
• B. Stage 4
• C. Stage 1
• D. Stage 2

Correct answer: D

Rationale:

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