Which of the following is usually the first symptom of a cataract that the nurse would expect a patient to report during assessment?

Correct Answer: B

Rationale: The correct answer is B: Blurring of vision. This is typically the first symptom of a cataract because the clouding of the lens causes light to scatter, leading to blurred vision. Dry eyes (A) and eye pain (C) are not typically associated with cataracts. Loss of peripheral vision (D) is more commonly seen in conditions like glaucoma. In summary, blurring of vision is the hallmark symptom of cataracts due to lens clouding, distinguishing it from other eye conditions.

Correct Answer: C

Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs. Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe. In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.

Correct Answer: C

Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used. Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly. Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride. Summary: - Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration. - Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride. - Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.

Correct Answer: D

Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications. Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Citrus fruits and green leafy vegetables. Citrus fruits and green leafy vegetables are good sources of Vitamin C and iron, which are essential for individuals with iron deficiency anemia. Vitamin C enhances the absorption of iron from plant-based sources, while green leafy vegetables provide iron. Bananas and nuts (choice B) are not significant sources of iron. Coffee and tea (choice C) can inhibit iron absorption. Dairy products (choice D) are not high in iron and can also inhibit iron absorption. Therefore, choosing citrus fruits and green leafy vegetables indicates understanding of the dietary instructions for managing iron deficiency anemia.

Correct Answer: C

Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure. Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications. Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow. Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.

Correct Answer: D

Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.

Correct Answer: A

Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.

Correct Answer: C

Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is important because the patient may not accurately express their pain level verbally. By addressing the discrepancy between the patient's verbal report and non-verbal cues, the nurse can gather more information to assess the patient's pain accurately. By directly communicating with the patient, the nurse can ensure that the appropriate interventions are provided. Choice A is incorrect because it disregards the need to address the patient's pain assessment. Choice B assumes the patient's preference without further clarification. Choice D jumps to administering pain medication without fully assessing the situation, which could lead to inappropriate treatment.