a client is having dificulties reading an educational pamphlet he cannot ind his glasses in order to read the words he must hold the pamphlet at arms
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Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?

Correct answer: D

Rationale: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.

2. The rehabilitation nurse wishes to make the following entry into a client's plan of care: 'Client will reestablish a pattern of daily bowel movements without straining within two months.' The nurse would write this statement under which section of the plan of care?

Correct answer: D

Rationale: The correct answer is 'Long-term goals.' Long-term goals are designed to describe changes in client behavior expected over a time frame greater than one week. In this case, the goal of reestablishing a pattern of daily bowel movements without straining within two months falls under a long-term goal. Long-term goals are aimed at restoring normal functioning in a problem area and are beneficial for healthcare workers caring for the client across different settings. Choices A, B, and C are incorrect because nursing diagnosis/problem list, nursing orders, and short-term goals do not encompass the desired timeframe or level of expected change in this scenario.

3. What technique would the nurse use to accurately assess a rectal temperature in an adult?

Correct answer: A

Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

4. What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?

Correct answer: A

Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.

5. During a class on the aspects of culture, the instructor shares that culture has four basic characteristics. Which statement correctly reflects one of the characteristics of culture?

Correct answer: D

Rationale: Culture has four basic characteristics, one of which is that it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. The other three characteristics are: (1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the cultural group; and (3) dynamic and ever-changing. Culture is not static and unchanging but is dynamic and ever-changing. Members of a culture do not necessarily share similar physical characteristics; that refers to race. Similarly, members of a culture do not necessarily share a common geographic origin and religion; that refers to ethnicity.

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