Describe nursing management of clients with impending or actual shock.

Correct Answer: A

Rationale: In the context of managing clients with impending or actual shock, the correct answer is option A) Decreased blood pressure. Shock is a life-threatening condition where the body's vital organs do not receive enough oxygen and nutrients due to inadequate perfusion. Decreased blood pressure is a hallmark sign of shock, indicating inadequate tissue perfusion. Nursing management in shock focuses on improving tissue perfusion and oxygenation. Option B) Increased heart rate is a compensatory mechanism in response to decreased blood pressure to maintain cardiac output. While this can be present in shock, it is not the primary focus of nursing management. Option C) Fluid retention is not typically seen in shock. In fact, fluid resuscitation is a key intervention in managing shock to improve circulating volume and perfusion. Option D) Muscle cramps are not a specific sign of shock. In shock, the body prioritizes perfusion to vital organs over peripheral tissues, which can lead to decreased perfusion to muscles, but muscle cramps are not a primary consideration in nursing management of shock. Understanding the signs and symptoms of shock, along with appropriate nursing interventions, is crucial for nurses caring for patients in critical condition. By recognizing the significance of decreased blood pressure in shock, nurses can promptly intervene to optimize patient outcomes and prevent further deterioration.

Correct Answer: C

Rationale: In an ophthalmic assessment, the nurse should observe pupil responses carefully. Pupil responses provide crucial information about the function of the autonomic nervous system and cranial nerves. Changes in pupil size and reaction can indicate neurological issues or drug effects. Option A, the level of central vision, while important, is typically assessed using a Snellen chart and is not part of a standard ophthalmic assessment. Option B, internal eye condition, requires specialized equipment like an ophthalmoscope and is usually assessed by ophthalmologists rather than nurses during routine assessments. Option D, rate of blinking, is not a primary focus of an ophthalmic assessment unless there are specific concerns like abnormal blinking patterns related to neurological conditions. Understanding the significance of pupil responses in assessing neurological function is crucial for nurses, especially in monitoring patients with head injuries, neurological conditions, or those under the influence of certain medications affecting pupil size or reaction.

Correct Answer: B

Rationale: In pharmacology, understanding how medications affect different body systems is crucial for safe and effective nursing practice. In this context, the question pertains to assessing hearing conduction methods in a client, which is important for monitoring drug side effects like ototoxicity. The correct answer is B) Rinne Test. The Rinne Test compares air conduction (using a tuning fork near the ear) with bone conduction (placing the tuning fork on the mastoid bone). In a normal test, air conduction should be greater than bone conduction. This test helps identify conductive hearing loss. A) The Romberg test assesses balance and proprioception, not hearing conduction. C) The Weber test is used to assess unilateral hearing loss, not air vs. bone conduction. D) Otoscopic examination is for assessing the external ear canal and eardrum, not for comparing air vs. bone conduction. Educationally, understanding these tests is vital for nurses to accurately assess and monitor patients' sensory functions, detect abnormalities early, and collaborate with healthcare providers for appropriate interventions. Mastering these assessments ensures holistic patient care and medication safety.

Correct Answer: C

Rationale: In a client who has just undergone cataract surgery, the nurse should closely monitor for and report immediately any intense pain in the eye or near the brow. This is the correct answer because intense pain in the eye or near the brow post-cataract surgery can indicate complications such as increased intraocular pressure, infection, or hemorrhage, which require prompt medical intervention to prevent further damage or vision loss. Option A, hypotension, is incorrect as it is not typically a common immediate concern following cataract surgery unless the patient has pre-existing cardiovascular issues or is on specific medications that could lead to hypotension. Option B, nausea and vomiting, while possible postoperatively, are not typically considered urgent unless they are accompanied by other concerning symptoms that indicate a more serious complication. Option D, increased urine output, is also not a typical immediate concern following cataract surgery and would not be a primary indicator of a complication related to the surgery itself. In an educational context, understanding the rationale behind closely monitoring for specific symptoms post-cataract surgery is crucial for nurses to provide safe and effective care to their patients. Recognizing and promptly reporting signs of potential complications can lead to timely interventions and improved patient outcomes.

Correct Answer: D

Rationale: In the context of pharmacology and medical-surgical nursing, confirming a client's understanding of instructions is crucial to ensure safe and effective care. Option D, which states "All of the above," is the correct answer. This is because utilizing a combination of strategies is the most comprehensive approach to confirming understanding. Option A, asking the client to repeat the instructions back, is important as it tests their ability to recall and understand the information provided. This can help identify any misunderstandings that need to be clarified. Option B, providing written instructions, is also important as it offers a visual aid that can enhance comprehension, especially for clients who are visual learners or may have difficulty with verbal communication. Option C, observing their behavior during implementation, is also key as it allows the healthcare provider to assess whether the client is carrying out the instructions correctly. However, solely relying on behavior observation may not always confirm understanding, as a client may go through the motions without truly comprehending the instructions. In an educational context, it is essential for nurses to employ multiple methods to confirm client understanding of pharmacological instructions. By incorporating various strategies such as verbal repetition, written materials, and observation, healthcare providers can ensure that clients have the knowledge and ability to properly follow medication regimens, thus promoting patient safety and optimal health outcomes.