The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?

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Question 1 of 9

The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?

Correct Answer: B

Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.

Question 2 of 9

A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results?

Correct Answer: C

Rationale: The correct answer is C: Western blot test. The Western blot test is considered the gold standard for confirming HIV diagnosis after a positive EIA result. It detects specific antibodies to HIV proteins, providing a more accurate confirmation. Other choices are incorrect because: A: Another EIA test would yield the same result as the initial EIA test. B: Viral load test measures the amount of virus in the blood and is not used to confirm HIV diagnosis. D: CD4/CD8 ratio is used to monitor immune status but not to confirm HIV diagnosis.

Question 3 of 9

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share?

Correct Answer: D

Rationale: The correct answer is D because saturated fats are primarily found in animal sources such as red meat, poultry, and dairy products. It is important to limit the intake of saturated fats on a low-fat diet to reduce the risk of heart disease and other health issues. A: Polyunsaturated fats are actually considered healthy fats and should not be restricted to less than 7% of total calories. B: Transfat is a type of unhealthy fat that should be avoided altogether, not just limited to 7% of total calories. C: Unsaturated fats are actually found mostly in plant-based sources like nuts, seeds, and avocados, not animal sources. In summary, choice D is correct because it provides accurate information about the source of saturated fats in animal products, while the other choices provide incorrect or misleading information about different types of fats.

Question 4 of 9

An oncology nurse is contributing to the care of a patient who has failed to respond appreciably to conventional cancer treatments. As a result, the care team is considering the possible use of biologic response modifiers (BRFs). The nurse should know that these achieve a therapeutic effect by what means?

Correct Answer: B

Rationale: The correct answer is B: Focusing the patient's immune system exclusively on the tumor. Biologic response modifiers (BRMs) work by enhancing the body's natural defenses to target and attack cancer cells specifically. This approach helps the immune system to recognize and destroy cancer cells while minimizing harm to normal cells. A: Promoting the synthesis and release of leukocytes - This is not the primary mechanism of action for BRMs. While leukocytes play a role in the immune response, BRMs target the immune system's response to tumors. C: Potentiating the effects of chemotherapeutic agents and radiation therapy - While some BRMs may be used in combination with these treatments, their primary mode of action is not to enhance the effects of chemotherapy or radiation therapy. D: Altering the immunologic relationship between the tumor and the patient - This choice is too broad and vague. BRMs specifically aim to direct the immune response towards targeting the tumor cells, rather than altering the overall immunologic relationship

Question 5 of 9

The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find?

Correct Answer: A

Rationale: Step-by-step rationale for why A is correct: 1. Retinal detachment causes traction on the retina. 2. Traction on the retina can stimulate photoreceptors. 3. Stimulation of photoreceptors can lead to perception of flashing lights. 4. Therefore, the characteristic symptom of retinal detachment is flashing lights in the visual field. Summary: B: Sudden eye pain is not a characteristic symptom of retinal detachment. C: Loss of color vision is not typically associated with retinal detachment. D: Colored halos around lights are more indicative of conditions like glaucoma or corneal edema, not retinal detachment.

Question 6 of 9

A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patients care in this setting be based

Correct Answer: C

Rationale: The correct answer is C: Meaningful living during terminal illness is best supported in the home. This is because hospice care focuses on providing compassionate care and support in the comfort of the patient's own home, which can enhance quality of life and dignity. Being in a familiar and comfortable environment allows the patient to receive personalized care and emotional support from family members. Options A, B, and D are incorrect because hospice care emphasizes comfort and quality of life over technologic interventions, designated facilities, and prolonging physiologic dying. Ultimately, the goal of hospice care is to prioritize the patient's emotional and physical well-being during the end stages of life.

Question 7 of 9

A nurse is explaining that each breast contains 12 to 20 cone-shaped lobes. The nurse should explain that each lobe consists of what elements?

Correct Answer: C

Rationale: The correct answer is C: Lobules and ducts. Each lobe of the breast consists of lobules, which are responsible for milk production, and ducts, which transport the milk to the nipple. This is essential for breastfeeding. Modified tendons and ligaments (choice A) are not present in the lobes of the breast. Connective tissue and smooth muscle (choice B) are important components of the breast but do not specifically make up the lobes. Endocrine glands and sebaceous glands (choice D) are not the primary elements within the lobes of the breast responsible for milk production and transport. The lobules and ducts are vital components for the functioning of the breast in lactation.

Question 8 of 9

Which postpartum patient reqNuUirResS fuIrNthGerT aBss.esCsmOeMnt?

Correct Answer: A

Rationale: The correct answer is A because the postpartum patient who has had four saturated pads during the last 12 hours should receive further assessment. This indicates excessive postpartum bleeding (postpartum hemorrhage), which is a critical complication that requires immediate intervention to prevent complications like hypovolemic shock. Monitoring vital signs, assessing for signs of shock, evaluating uterine tone, and determining the cause of bleeding are crucial steps in managing postpartum hemorrhage. Choices B, C, and D are not the correct answers because: B: A patient with Class II heart disease complaining of frequent coughing is more likely experiencing cardiac-related issues and requires evaluation and management by a cardiologist. C: A patient with gestational diabetes and a fasting blood sugar level of 100 mg/dL is within the normal range and does not require immediate further assessment. D: A postcesarean patient with active herpes lesions on the labia requires appropriate management of the herpes infection but does not necess

Question 9 of 9

A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Hearing-impaired patient is likely unable to hear during an MRI due to loud noises. 2. Nurse needs to use alternative communication methods like writing or gestures. 3. Sign language interpreter may not be necessary for an MRI. 4. Lip reading may be challenging due to the noisy MRI environment. 5. Interaction should be adapted to accommodate the patient's communication needs.

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