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.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"A"}

Explanation

Rationale:

• An endoscopy is necessary to visualize the upper gastrointestinal tract for potential ulcers or bleeding sites, especially given the client’s positive fecal occult blood and anemia. This procedure will help identify active bleeding and confirm a diagnosis of peptic ulcer disease.

• An antifungal prescription is inappropriate because there is no evidence of fungal infection such as thrush or candidiasis. The client’s symptoms and diagnostic findings are more consistent with a gastrointestinal disorder, particularly peptic ulcer disease.

• Oxygen via nonrebreather mask is not indicated because the client's oxygen saturation is normal at 98% on room air. There are no respiratory symptoms or signs of hypoxia that would necessitate supplemental oxygen at this level of intensity.

• Low hemoglobin and hematocrit indicate a state of anemia, which is likely due to chronic gastrointestinal bleeding. The client’s history of dark, tarry stools (melena) further supports ongoing blood loss from the upper GI tract, necessitating diagnostic evaluation.

• History of gnawing epigastric pain is suggestive of peptic ulcer disease but does not on its own justify urgent endoscopy. This history becomes more significant when paired with other alarming signs like bleeding or anemia, but alone it is not a definitive indicator.

• Stool test results showing a positive hemoccult test confirm the presence of gastrointestinal bleeding. Combined with anemia and pain, this is a key indicator for immediate endoscopic evaluation to locate and treat the bleeding source.

• H. pylori results support a peptic ulcer etiology, but the infection alone does not require urgent visualization unless there are complications like bleeding, anemia, or severe symptoms, which would necessitate further diagnostic action.

• Presence of epigastric tenderness is a non-specific physical finding that could result from many conditions and is not sufficient to determine the need for endoscopy without other supportive clinical evidence pointing toward bleeding or ulceration.

• Smoking and alcohol intake history increase the risk for peptic ulcer disease but are not acute indicators for endoscopy. They contribute to the etiology and chronic risk but do not demonstrate the immediate need for invasive diagnostics.

A. "I should use a firm mattress in my baby's crib." B. "I should set my hot water heater at 130 degrees Fahrenheit." C. “I should use a crib with side rails that drop" D. "I should position my baby on their stomach to sleep during the day."

Correct Answer is A

Explanation

Rationale:

A. "I should use a firm mattress in my baby's crib.": A firm mattress reduces the risk of sudden infant death syndrome (SIDS) and suffocation by providing a stable, flat surface for safe infant sleep. This is a key recommendation in safe sleep guidelines.

B. "I should set my hot water heater at 130 degrees Fahrenheit.": Setting the water heater at 130°F increases the risk of scald burns, especially for infants and young children. The recommended temperature to prevent burns is 120°F or lower.

C. “I should use a crib with side rails that drop": Drop-side cribs have been banned due to safety concerns, including risk of entrapment and suffocation. Using a crib with fixed side rails is safer and recommended.

D. "I should position my baby on their stomach to sleep during the day.": Placing infants on their stomach to sleep increases the risk of SIDS. The safest position for sleep is on the back, both during the day and night.

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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 assisting with the care of a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require dropdown as evidenced by the client's dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"A"}

Explanation

A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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