when assessing a client with glaucoma a nurse expects which of the following findings
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Nursing Elites

NCLEX-PN

Psychosocial Integrity Nclex PN Questions

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

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. During discharge teaching for a client with diverticulitis on a low-roughage diet, which food should be eliminated from the diet?

Correct answer: C

Rationale: The client with diverticulitis needs to avoid gas-forming foods that can increase abdominal discomfort. Cooked broccoli is a high-fiber food that can worsen symptoms. Roasted chicken, noodles, and custard are suitable choices for a low-roughage diet as they are less likely to cause gas formation or abdominal discomfort.

3. An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?

Correct answer: D

Rationale: One of the significant barriers for elderly clients to admit being victims of abuse is the fear of reprisal or further violence if the incident is reported. Elderly individuals may be afraid of the consequences of reporting abuse, such as retaliation or increased violence from the abuser. This fear can prevent them from disclosing their victimization. Choices A and C are incorrect as knowledge of the rarity of elder abuse and the availability of appropriate screening tools do not directly impact the client's willingness to admit abuse. Choice B, personal belief that abuse is deserved, may be a factor for some individuals but is not as common or impactful as the fear of reprisal or further violence.

4. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?

Correct answer: A

Rationale: Bilirubin is excreted through the kidneys, therefore increasing fluid intake can help facilitate its elimination. Maintaining the infant's body temperature is important for overall health but does not directly assist in eliminating bilirubin, making choice B incorrect. Choices C and D are irrelevant to bilirubin elimination in this scenario and do not address the specific issue of physiologic jaundice.

5. When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, what should the nurse do?

Correct answer: C

Rationale: When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, it is crucial to address the issue promptly and effectively. Confronting the staff member immediately in front of the client may worsen the situation by enhancing the division of staff and compromising client care. Writing an incident report, although important for documentation, may not address the immediate need to correct the behavior. Bringing up the incident during a weekly conference may not be the most effective approach for immediate resolution. Asking the staff member to talk in private and reinforcing how antisocial clients try to divide staff is the best option. This approach allows for a constructive conversation to address the issue, provide education, and help the staff member develop skills to work effectively with this client population.

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