Nursing Elites

1. When assessing a client with glaucoma, a nurse expects which of the following findings?

• A. Complaints of double vision
• B. Complaints of halos around lights
• C. Intraocular pressure of 15 mm Hg
• D. Soft globe on palpation

Correct answer: B

Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.

2. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

• A. Decreased appetite
• B. A low-grade fever
• C. Chest congestion
• D. Constant swallowing

Correct answer: D

Rationale: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade fever; thus, answers A and B are incorrect. Chest congestion, as mentioned in answer C, is not typical of tonsillectomy complications, making it an incorrect choice.

3. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.

4. A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:

• A. the client's body has developed tolerance, requiring more drug to produce the same effect.
• B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence.
• C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance.
• D. the client has a dual diagnosis of substance abuse and chronic back pain

Correct answer: A

Rationale: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effects and decreased sensitivity to the substance. In this scenario, the client needing an increased dose of hydrocodone to achieve the same pain relief indicates tolerance developing, not addiction. Choice B is incorrect as it describes drug dependence, where the individual is preoccupied with the drug and has a loss of control. Choice C is incorrect because addiction involves psychological behaviors related to substance use, not just physical dependence with withdrawal symptoms and tolerance. Choice D is incorrect as it refers to a dual diagnosis, which is the coexistence of substance abuse and psychiatric disorders, not the development of tolerance to a drug.

5. The best definition of communication is:

• A. the sending and receiving of messages.
• B. the effect of sending verbal messages.
• C. an ongoing, interactive form of transmitting transactions.
• D. the use of message variables to send information.

Correct answer: C

Rationale: Communication is defined as an ongoing, interactive form of transmitting transactions. It involves a dynamic process of sending (encoding) and receiving (decoding) messages while being influenced by the experiences and perceptions of both the sender and receiver. This process is interactive and occurs within an environment, shaping individuals' self-concept, identity, and relationships. The correct answer captures the complexity and interactive nature of communication. Choice A, 'the sending and receiving of messages,' is too simplistic and does not encompass the interactive nature of communication. Choice B, 'the effect of sending verbal messages,' focuses solely on verbal communication and overlooks non-verbal forms. Choice D, 'the use of message variables to send information,' emphasizes technical aspects rather than the interactive and transactional nature of communication.

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