Nursing Elites

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

• A. Once retinal detachment occurs, it does not return to its normal state
• B. Once the tissue has necrosed from high-pressure, it does not regenerate
• C. Glaucoma always leads to permanent blindness
• D. Once bacterial infection has caused damage, the tissue does not regenerate

Correct answer: B

Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.

2. The medical record for a client states that the client has hemiplegia. What does this mean?

• A. The client can use his right arm, left leg, and left arm.
• B. The client has paralysis of all four extremities.
• C. The client has decreased vision in one eye.
• D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

3. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

• A. Creamy pus
• B. Serous
• C. Serosanguineous
• D. Purulent exudate

Correct answer: C

Rationale:

4. What nursing intervention is best to improve communication with a hearingimpaired client?

• A. Talk in a regular voice in the good ear
• B. Talk loudly in the impaired ear
• C. Write down the message
• D. Speak slowly and clearly while facing the client

Correct answer: D

Rationale:

5. 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:

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