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 nurse is performing an assessment on a patientwho has not had a bowel movement in 3 days. The nurse will expect which other assessment finding?

Correct Answer: A

Rationale: The correct answer is A: Hypoactive bowel sounds. When a patient has not had a bowel movement in 3 days, it indicates constipation. Constipation can lead to decreased peristalsis, resulting in hypoactive bowel sounds. Increased fluid intake (B) would be a potential intervention, not an expected assessment finding. A soft tender abdomen (C) may indicate other issues like inflammation or infection, not directly related to constipation. Jaundice in the sclera (D) is indicative of liver dysfunction, not a typical finding associated with constipation.

Question 3 of 9

A patient who is scheduled for an open prostatectomy is concerned about the potential effects of the surgery on his sexual function. What aspect of prostate surgery should inform the nurses response?

Correct Answer: B

Rationale: Step 1: Prostate surgery can damage nerves responsible for erectile function. Step 2: Nerve damage can lead to erectile dysfunction post-prostatectomy. Step 3: Choice B correctly states that all prostatectomies carry a risk of nerve damage and consequent erectile dysfunction, aligning with the potential impact of surgery on sexual function. Step 4: Other choices lack accuracy: A incorrectly attributes erectile dysfunction solely to hormonal changes, C falsely suggests temporary nature of dysfunction, and D wrongly claims no risk of dysfunction due to modern techniques.

Question 4 of 9

Which clinical intervention is the only known cure for preeclampsia?

Correct Answer: B

Rationale: The correct answer is B: Delivery of the fetus. The only known cure for preeclampsia is the delivery of the fetus, as this condition typically resolves after giving birth. Since preeclampsia can lead to serious complications for both the mother and baby, delivering the fetus is the most effective way to stop the progression of the condition. Magnesium sulfate (choice A) is used to prevent seizures in women with severe preeclampsia but does not cure the condition. Antihypertensive medications (choice C) are used to manage blood pressure in preeclampsia but do not cure it. Administration of aspirin (choice D) is used for prevention, not as a cure for preeclampsia.

Question 5 of 9

After contributing to the care of several patients who died in the hospital, the nurse has identified some lapses in the care that many of these patients received toward the end of their lives. What have research studies identified as a potential deficiency in the care of the dying in hospital settings?

Correct Answer: A

Rationale: The correct answer is A. Research studies have consistently shown that families' needs for information and support often go unmet in hospital settings when caring for dying patients. This is a crucial deficiency as effective communication and support for families can greatly impact the quality of care provided to the dying patient. When families are not adequately informed and supported, it can lead to increased stress, confusion, and dissatisfaction with the care provided. Choices B, C, and D are incorrect because they do not address the specific deficiency identified in research studies. While pain control, communication, and attention from caregivers are important aspects of end-of-life care, the primary focus in this scenario is on the unmet needs of families for information and support. Ignoring families' needs can have significant negative consequences on the overall care provided to the dying patient.

Question 6 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 7 of 9

A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin?

Correct Answer: D

Rationale: The correct answer is D: Immunoglobulin E. The atopic response in allergies is mainly mediated by IgE antibodies. IgE binds to allergens and triggers the release of histamine and other chemicals that cause allergic symptoms. IgA is mainly found in mucosal areas, IgM is involved in early immune responses, and IgG is important for long-term immunity. IgE is specifically associated with allergic reactions due to its role in sensitizing mast cells and basophils to allergens.

Question 8 of 9

The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient?

Correct Answer: A

Rationale: The correct answer is A: Leukopenia. Taxol and Paraplatin are known to cause bone marrow suppression, leading to decreased white blood cell counts. Leukopenia can increase the patient's risk of infection, so monitoring for signs of infection is crucial. Metabolic acidosis, hyperphosphatemia, and respiratory alkalosis are not typically associated with Taxol and Paraplatin chemotherapy.

Question 9 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.

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