The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

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Question 1 of 5

The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

Correct Answer: C

Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid. Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.

Question 2 of 5

An ICU nurse has provided excellent care for a 6-year-old girl who had been admitted to the ICU for a head injury. The nurse was attentive not only to the needs of the patient but also went out of her way to care for the needs of the girls family. According to research, which of the following forms of recognition would the nurse value the most?

Correct Answer: A

Rationale: Rationale: The correct answer is A: A card from the girl's family. The nurse would value this form of recognition the most because it directly reflects the impact of her care on the patient and her family. It is a personal, heartfelt gesture that acknowledges the nurse's compassion and dedication. A card from the family shows genuine appreciation and gratitude for the nurse's efforts, making it the most meaningful form of recognition. Summary: - Choice B: A plaque from the ICU physicians could be seen as a formal recognition but lacks the personal touch and direct impact of the nurse's care on the patient and family. - Choice C: A letter of commendation from the hospital's administration is a professional acknowledgment but may not capture the emotional connection and impact that the nurse had on the family. - Choice D: A bouquet of flowers from her supervisor is a nice gesture but does not necessarily reflect the specific impact of the nurse's care on the patient and family.

Question 3 of 5

A nurse has achieved certification in critical care nursing. What is the most important effect that this certification will have on the nurses practice?

Correct Answer: D

Rationale: The correct answer is D: Increased confidence in critical thinking. Achieving certification in critical care nursing validates the nurse's expertise and knowledge in this specialized area, leading to increased confidence in their ability to critically think through complex patient situations. This confidence translates into improved clinical decision-making and patient outcomes. A: Recognition by peers - While recognition by peers is important for professional growth, the primary benefit of certification is enhancing clinical skills. B: Increase in salary and rank - While certification may lead to salary increases in some cases, the most significant impact is on improving clinical skills. C: More flexibility in seeking employment - While certification may enhance employability, the focus is on improving critical thinking skills rather than employment opportunities.

Question 4 of 5

A nurse wishes to practice using the Synergy Model developed by the American Association of Critical-Care Nurses (AACN). What nursing behavior best supports use of this model?

Correct Answer: B

Rationale: The correct answer is B: Self-directed study of best practice for the patients she cares for. This choice aligns with the Synergy Model by promoting individualized patient care based on best practices. Self-directed study allows the nurse to enhance their knowledge and skills to provide optimal care tailored to each patient's unique needs. Attending mandatory in-service programs (A) may not directly support the individualized care approach. Gathering demographic data (C) is important but not specific to the Synergy Model's focus on patient acuity and nurse competencies. Participating in a research study (D) may contribute to evidence-based practice, but it does not directly relate to the Synergy Model's emphasis on aligning nurse competencies with patient needs.

Question 5 of 5

A patient is admitted to the ICU with injuries sustained from a fall from a third-story window. The patient is conscious, his breathing is labored, and he is bleeding heavily from the abdomen. He groans constantly and complains of severe pain, but his movements are minimal. His heart rate is elevated. Which of these is a sign that he is in the second phase of the stress response? Select all that apply.

Correct Answer: C

Rationale: The correct answer is C: Severe pain. In the second phase of the stress response (resistance phase), the body is trying to cope with the stressor. Severe pain is a sign of the body's response to the injury, indicating the activation of the stress response. Labored breathing and elevated heart rate are more likely to be signs of the initial phase (alarm phase) of the stress response. Bleeding heavily from the abdomen is a medical emergency and does not specifically indicate the stress response phase.

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