Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?

Correct Answer: C

Rationale: Halos around lights are a common symptom observed in patients experiencing acute angle-closure glaucoma. This occurs due to the increased intraocular pressure causing corneal edema, which leads to light scattering and the appearance of halos. Other symptoms may include severe eye pain, redness in the eye, decreased vision, and headache. It is important for the nurse to recognize these symptoms promptly as acute angle-closure glaucoma is a medical emergency that requires immediate treatment to prevent permanent vision loss.

Correct Answer: C

Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.

Correct Answer: A

Rationale: Administering oxygen therapy would be the priority intervention in this case because Arthur is experiencing pneumonia with a high fever (39° to 40° C). High fever can lead to increased oxygen demand in the body, and providing supplemental oxygen can help ensure that Arthur is receiving adequate oxygenation to support his respiratory function. Oxygen therapy can also help improve oxygen saturation levels, which may be compromised due to the pneumonia. Therefore, addressing the potential respiratory distress caused by the pneumonia and fever should be the top priority to optimize Arthur's oxygenation levels and respiratory function.

Correct Answer: D

Rationale: A herniated nucleus pulposus at the C4-C5 and C5-C6 interspace typically results in neck and shoulder pain, which can radiate to the scapular region. The herniation at these levels can cause irritation or compression of the cervical nerve roots leading to pain, numbness, tingling, or weakness in the affected areas. Constant, throbbing headaches are not typically associated with this specific diagnosis. Clonus in the lower extremities and numbness of the face are also not common findings related to herniated nucleus pulposus at the cervical spine levels mentioned.

Correct Answer: A

Rationale: Cystoclisis refers to the continuous irrigation of the bladder with a sterile solution to maintain bladder atony. This procedure is commonly done to provide continuous bladder drainage, prevent clot formation, and promote urinary flow. By continuously irrigating the bladder, it helps to keep the bladder decompressed and prevent the overdistension of the bladder muscles, especially in patients with impaired bladder emptying or bladder dysfunction. Therefore, the purpose of cystoclisis is to increase bladder atony rather than the other options listed.