A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Nystagmus

Astigmatism

Loss of central vision

Client reports sharp pain

Answer and Explanation

The Correct Answer is C

Rationale:

A. Nystagmus: Nystagmus is characterized by involuntary eye movements and is typically associated with vestibular disorders, multiple sclerosis, or congenital conditions. It is not a symptom of macular degeneration, which primarily affects the retina.

B. Astigmatism: Astigmatism is a refractive error due to an irregularly shaped cornea or lens. It is unrelated to macular degeneration, which involves degeneration of the macula—the part of the retina responsible for sharp central vision.

C. Loss of central vision: Macular degeneration leads to progressive deterioration of the macula, resulting in blurred or complete loss of central vision while peripheral vision remains intact. This is a hallmark symptom and significantly affects activities like reading and recognizing faces.

D. Client reports sharp pain: Macular degeneration does not typically cause pain. It is a painless condition, and the presence of sharp eye pain may suggest another acute ocular issue such as glaucoma or injury, not related to macular changes.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Use an N95 respirator: N95 respirators are necessary for airborne precautions, such as with tuberculosis or measles. C. difficile is transmitted via contact with contaminated surfaces or stool, not airborne particles, so an N95 is not indicated.

B. Initiate contact precautions: Contact precautions are required for C. difficile because it spreads through direct and indirect contact with contaminated surfaces or stool. Gloves and gowns should be worn, and hand hygiene with soap and water is essential to prevent spore transmission.

C. Place the child in a room that has a HEPA filtration system: HEPA filters are used for airborne pathogens or immunocompromised clients, not for enteric infections like C. difficile. This intervention would not reduce transmission risk in this case.

D. Instruct the parents to avoid bringing fresh flowers into the room: This precaution is typically for neutropenic or immunocompromised clients to reduce exposure to potential fungal spores. C. difficile precautions focus on containment of fecal-oral transmission routes, not environmental fungal sources.

A. Instruct the client to lie supine with his knees flexed. B. Cover the wound with a dry sterile dressing C. Position the client in semi-Fowler's position. D. Cover the wound with a transparent dressing

Correct Answer is A

Explanation

Rationale:

A. Instruct the client to lie supine with his knees flexed: Flexing the knees reduces tension on the abdominal wall and helps prevent further protrusion of abdominal contents. This position is critical for stabilizing the evisceration while awaiting surgical intervention.

B. Cover the wound with a dry sterile dressing: Using a dry dressing can cause the exposed organs to dry out and adhere to the material, increasing the risk of tissue damage. A moist sterile dressing is needed to protect and preserve the protruding tissues.

C. Position the client in semi-Fowler's position: Elevating the head of the bed increases intra-abdominal pressure and can worsen evisceration. This position should be avoided to prevent strain on the open surgical site.

D. Cover the wound with a transparent dressing: Transparent dressings are not suitable for eviscerations because they do not provide adequate moisture or protection for exposed organs. A sterile saline-moistened dressing is required to maintain tissue integrity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

The nurse has reviewed the Vital Signs at 1000. Exhibits For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?

A nurse is caring for an adolescent who requests screening for sexually transmitted infections (STI). The client asks the nurse. "Do you have to tell my parents?" How should the nurse respond to the adolescent?

The nurse continues to assist in the care of the client. Exhibits Complete the following sentence by using the lists of options. The nurse should first ensure administration of the client's e to the client's dropdown due to the client’s dropdown.