Nursing Elites

1. An adult who was recently diagnosed with glaucoma tells the nurse, 'it feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

• A. Maintain prescribed eye drop regimen
• B. Avoid frequent eye pressure measurements
• C. Wear prescription glasses
• D. Eat a diet high in carotene

Correct answer: A

Rationale: The correct answer is A: Maintain prescribed eye drop regimen. In glaucoma, maintaining the prescribed eye drop regimen is crucial for controlling intraocular pressure, which helps in preventing vision loss. Consistent use of eye drops as directed can slow down the progression of the disease and preserve vision. Choice B is incorrect because avoiding frequent eye pressure measurements does not address the primary treatment for glaucoma. Choice C is incorrect as wearing prescription glasses may be helpful for vision correction but does not directly address the management of glaucoma. Choice D is incorrect because while a diet high in carotene may promote overall eye health, it is not the most important instruction for managing glaucoma.

2. In the staging process of Hodgkin's disease, what does Stage I indicate?

• A. Involvement of a single lymph node.
• B. Involvement of two or more lymph nodes on the same side of the diaphragm.
• C. Involvement of lymph node regions on both sides of the diaphragm.
• D. Involvement of diffuse disease of one or more extralymphatic organs.

Correct answer: A

Rationale: In the staging process of Hodgkin's disease, Stage I signifies the involvement of a single lymph node. This stage indicates localized disease with the disease being limited to a single lymph node or a group of adjacent nodes. Choices B, C, and D are incorrect because they describe more extensive involvement of lymph nodes, both sides of the diaphragm, or extralymphatic organs, which would correspond to higher stages in the staging system.

3. A client with peripheral arterial disease (PAD) has cool and pale feet with diminished pulses. Which of the following interventions should the nurse implement?

• A. Keep the legs elevated above the level of the heart.
• B. Encourage the client to exercise daily.
• C. Apply warm compresses to the affected area.
• D. Apply ice packs to the affected area.

Correct answer: C

Rationale: In peripheral arterial disease (PAD), there is decreased blood flow to the extremities. Applying warm compresses helps dilate blood vessels, improve circulation, and relieve symptoms. Elevating the legs above the heart level may further compromise blood flow. Encouraging daily exercise is important in PAD management but may not be appropriate when the client has cool, pale feet with diminished pulses. Applying ice packs can worsen vasoconstriction and further reduce blood flow, exacerbating symptoms in PAD.

4. After a lumbar puncture, into which position does the nurse assist the client?

• A. Flat
• B. Semi-Fowler
• C. Side-lying with the head of the bed elevated
• D. Sitting up in a recliner with the feet elevated

Correct answer: A

Rationale: After a lumbar puncture, the client should be positioned flat. This position helps prevent post-procedure spinal headaches and cerebrospinal fluid leakage. Keeping the client flat for up to 12 hours is crucial in minimizing these risks. Choices B, C, and D are incorrect because elevating the head of the bed or sitting up can increase the risk of complications by altering the pressure in the spinal canal, potentially leading to headaches and fluid leakage.

5. A client’s baseline vital signs are temperature 98°F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever to 103°F. Which of the following respiratory rates would the nurse anticipate as part of the body’s response to the change in client status?

• A. 12 breaths/min
• B. 16 breaths/min
• C. 18 breaths/min
• D. 22 breaths/min

Correct answer: D

Rationale: When a client experiences a fever, there is an increase in body temperature, leading to a higher metabolic rate and oxygen demand. As a result, the respiratory rate typically increases to meet the body's increased oxygen needs. Therefore, in response to the fever spike from 98°F to 103°F, the nurse would anticipate a higher respiratory rate. Choices A, B, and C are incorrect because a decrease in body temperature, not an increase as seen in fever, would lead to a decrease in respiratory rate to conserve energy and oxygen consumption.

Similar Questions