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. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?

• A. I am sorry you did not understand. Would you like a different doctor?
• B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
• C. You will need to have glasses.
• D. This means you won’t ever need glasses.

Correct answer: B

Rationale: 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.

3. A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

• A. Traumatic injury
• B. Pressure injury
• C. Friction injury
• D. Shearing injury

Correct answer: D

Rationale:

4. What nursing interventions increase the risk the pressure injuries?

• A. Padding hard surfaces
• B. Have client sit in wheelchair as much as possible
• C. Place pillows between bony surfaces
• D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

5. 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?

• A. Remove the nursing diagnosis in the plan of care since it has not occurred
• B. Change the nursing diagnosis in plan of care to impaired mobility
• C. Modify the nursing diagnosis in plan of care to impaired skin integrity
• D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct answer: D

Rationale:

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