while completing a health history the client reports experiencing blurring of vision in both eyes without associated pain what condition does the nurs

ATI RN

Multi Dimensional Care | Final Exam

1. While completing a health history the client reports experiencing blurring of vision in both eyes without associated pain. What condition does the nurse suspect?

A. Macular degeneration
B. Cataract
C. Retinal detachment
D. Glaucoma

Correct answer: B

Rationale: Cataracts can cause blurring of vision in both eyes without associated pain.

2. A nurse is caring for an immobile client. What is the priority assessment of this client?

A. Palpate for edema
B. Auscultate for bowel sounds
C. Inspect the skin for injury
D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

3. What is the intended outcome for the treatment of glaucoma?

A. Improve the vision of the eye
B. Strengthen the muscles of the eye
C. Lower the intraocular pressure
D. Dry up excess secretions

Correct answer: C

Rationale: The correct answer is C: Lower the intraocular pressure. The primary objective of treating glaucoma is to reduce intraocular pressure to prevent further vision loss. Choice A, 'Improve the vision of the eye,' is incorrect because while treatment may prevent vision loss, it does not necessarily improve vision. Choice B, 'Strengthen the muscles of the eye,' is incorrect as glaucoma primarily involves the optic nerve and not muscle weakness. Choice D, 'Dry up excess secretions,' is not related to the treatment goal of glaucoma which is focused on managing intraocular pressure.

4. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

A. Send the client back to surgery
B. Assess the wound for signs of dehiscence
C. Call the provider immediately
D. Prepare to culture the wound

Correct answer: B

Rationale:

5. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.