a client does not understand why vision loss due to glaucoma is irreversible what is the nurses best explanation

ATI RN

Multi Dimensional Care | Exam | Rasmusson

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. A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?

A. Primary intention
B. Binary intention
C. Secondary intention
D. None of the Above

Correct answer: A

Rationale:

3. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
C. The UAP carefully empties the indwelling catheter bag
D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

4. A client has a new arm cast. What is incorrect teaching by the nurse?

A. Use a sling to alleviate fatigue
B. Elevate the arm above the heart to reduce swelling
C. Report ‘hot spots’ felt under the cast
D. Sudden increase in drainage is expected

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

5. 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.