In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?

Mild headaches

Cloudiness that worsens at night

Severe eye pain

Mild eye pain

Answer and Explanation

The Correct Answer is C

Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.

Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.

Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.

Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.

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Correct Answer is C

Explanation

Choice A reason: Increased urinary output is not a manifestation of peritonitis. Peritonitis affects the peritoneal cavity, leading to abdominal symptoms rather than changes in urinary output.

Choice B reason: Hyperactive bowel sounds can occur in various gastrointestinal conditions but are not specific to peritonitis. Peritonitis typically presents with abdominal pain and tenderness.

Choice C reason: Abdominal tenderness/pain is a key manifestation of peritonitis. Inflammation of the peritoneum causes significant discomfort, and patients may also exhibit signs of infection such as fever and increased white blood cell count.

Choice D reason: Bradycardia is not commonly associated with peritonitis. Peritonitis primarily affects the abdominal cavity and may lead to systemic symptoms like fever and tachycardia, but not typically bradycardia.

A. "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots." B. "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain." C. "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them."

Correct Answer is B

Explanation

Choice A reason: The statement "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots" is incorrect. Atrial fibrillation primarily causes blood to pool in the atria, not the legs.

Choice B reason: The statement "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain" accurately explains the risk of clot formation in atrial fibrillation and the importance of anticoagulant therapy to prevent strokes and other complications.

Choice C reason: The statement "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them" is incorrect. Anticoagulant therapy in atrial fibrillation is used to prevent clot formation due to the arrhythmia itself, not as a counteraction to the side effects of other medications.

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In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

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In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?