acute hyphema is associated with what type of injury

NCLEX-PN

Nclex PN Questions and Answers

1. What type of injury is associated with acute hyphema?

A. orthopedic
B. eye
C. insect sting or snakebite
D. gynecological trauma

Correct answer: B

Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.

2. What can happen if a restraint is attached to a side rail or other movable part of the bed?

A. Do nothing to the client.
B. Injure the client if the rail or bed is moved.
C. Help the client stay in the bed without falling out.
D. Help the client with better posture.

Correct answer: B

Rationale: Attaching a restraint to a movable part of the bed can lead to client injury if that part of the bed is moved before releasing restraints. This could result in the client getting caught or trapped, possibly causing harm. Choices C and D are incorrect because attaching restraints to movable parts of the bed is not intended to help the client stay in bed or improve posture; rather, it poses a risk of injury. Choice A is incorrect as it does not address the potential harm associated with using restraints on movable parts of the bed.

3. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

A. Place the client in isolation until further assessment is completed.
B. Seclude the client from other clients and visitors.
C. Perform no intervention until test results confirm a diagnosis.
D. Don personal protective equipment immediately.

Correct answer: B

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.

4. To what does legal protection of confidentiality extend?

A. Written documentation only.
B. Electronic dissemination of information not identifiable to a specific client.
C. Only within the court system.
D. Both written and verbal information.

Correct answer: D

Rationale: Legal protection of confidentiality extends to both written and verbal information that is identifiable as individual private health information. Confidentiality in healthcare settings is vital to protect patients' privacy and trust. Choice A is incorrect because legal protection covers verbal information as well, not just written documentation. Choice B is incorrect as it mentions information not identifiable to a specific client, which wouldn't fall under legal protection of confidentiality. Choice C is incorrect as confidentiality extends beyond just the court system, impacting various healthcare settings and interactions. Therefore, the correct answer is D.

5. Which of the following tasks are appropriate for an LPN to perform?

A. Adjusting the cervical traction device of a 68-year-old client as instructed by the charge nurse.
B. performing operation on a woman in labour
C. Assessing a 36-year-old man newly admitted for chest pain.
D. Obtaining an occult blood sample from a 16-year-old client with ulcerative colitis.

Correct answer: D

Rationale: Tasks appropriate for an LPN to perform include teaching, obtaining samples, and documenting. LPNs can educate clients on care practices, such as teaching a new mother how to care for her baby. Obtaining samples, like an occult blood sample, falls within the scope of an LPN's responsibilities. Assessments, especially initial assessments, should be conducted by a registered nurse or physician, making option C incorrect. Adjusting devices like a cervical traction device should be done based on direct orders from prescribing providers, not charge nurses, making option A inappropriate for an LPN's role.