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Essential Concepts II

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This quiz is for the Essential Concepts II Unit of the RN Review Series. Good Luck!

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Question 1 of 20

1. Question
The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. Before placing the client in Trendelenburg position, the nurse should assess the client for
- Long bone fractures
- Air embolus
- Head injury
- Thrombophlebitis
Correct

#1 is not correct. Long bone fractures would not necessarily be a contraindication for Trendelenburg position.
#2 is not correct. A person who has an air embolus should be placed with the head lower than the chest.
#3 is correct. A person who has a head injury should not be placed in Trendelenburg position, as this would increase intracranial pressure.
#4 is not correct. A person who has thrombophlebitis should have the affected leg elevated.

Incorrect

#1 is not correct. Long bone fractures would not necessarily be a contraindication for Trendelenburg position.
#2 is not correct. A person who has an air embolus should be placed with the head lower than the chest.
#3 is correct. A person who has a head injury should not be placed in Trendelenburg position, as this would increase intracranial pressure.
#4 is not correct. A person who has thrombophlebitis should have the affected leg elevated.
Question 2 of 20

2. Question
The nurse is caring for a client who has gastroenteritis and is also taking digitalis. Her lab values are: K 3.2 mEq/L; Na 136 mEq/L; Ca 4.8 mEq/L; and Cl 98 mEq/L. What should the nurse include in the client’s plan of care?
- Monitor for hyperkalemia.
- Avoid foods rich in potassium.
- Observe for digitalis toxicity.
- Observe for Trousseau's and Chvostek's sign.
Correct

#1 is not correct. The client is in hypokalemia so the nurse would not monitor for hyperkalemia.
#2 is not correct. The client is in hypokalemia so the nurse would not avoid potassium rich foods.
#3 is correct. The client is hypokalemic. Digitalis toxicity occurs more readily in clients who have low serum potassium.
#4 is not correct. Trousseau and Chvostek signs are indicators of hypocalcemia and not relevant in this situation.

Incorrect

#1 is not correct. The client is in hypokalemia so the nurse would not monitor for hyperkalemia.
#2 is not correct. The client is in hypokalemia so the nurse would not avoid potassium rich foods.
#3 is correct. The client is hypokalemic. Digitalis toxicity occurs more readily in clients who have low serum potassium.
#4 is not correct. Trousseau and Chvostek signs are indicators of hypocalcemia and not relevant in this situation.
Question 3 of 20

3. Question
The client is receiving an infusion of Dextrose 5% and 0.45% normal saline at 125 mL/hour through an infusion pump. Which action of the new graduate nurse needs further attention from the charge nurse?
- Ensuring that the volume infused coincides with the time tape on the intravenous container.
- Adjusting the height of pump attachment to ensure that the intravenous fluid flows by gravity.
- Ensuring that the intravenous tubes are not pinched or blocked.
- Including the infusion device used in the documentation of the intravenous therapy.
Correct

#1 is not correct. Ensuring that the volume infused coincides with the tape on the container is appropriate if there is a tape on the container. This action is appropriate and does not indicate a need for further attention from the charge nurse.
#2 is correct. It is not necessary to adjust the height of the pump attachment to ensure that the intravenous fluid flows by gravity. Infusion pumps do not depend on gravity pressure. It can be placed at any level. This action by the nurse indicates a need for further attention from the charge nurse.
#3 is not correct. The nurse should be sure that the tubes are not pinched or blocked. This action is appropriate and does not indicate a need for further attention from the charge nurse.
#4 is not correct. Documenting the type of infusion device is appropriate and does not indicate a need for further attention from the charge nurse.

Incorrect

#1 is not correct. Ensuring that the volume infused coincides with the tape on the container is appropriate if there is a tape on the container. This action is appropriate and does not indicate a need for further attention from the charge nurse.
#2 is correct. It is not necessary to adjust the height of the pump attachment to ensure that the intravenous fluid flows by gravity. Infusion pumps do not depend on gravity pressure. It can be placed at any level. This action by the nurse indicates a need for further attention from the charge nurse.
#3 is not correct. The nurse should be sure that the tubes are not pinched or blocked. This action is appropriate and does not indicate a need for further attention from the charge nurse.
#4 is not correct. Documenting the type of infusion device is appropriate and does not indicate a need for further attention from the charge nurse.
Question 4 of 20

4. Question
An adult underwent emergency surgery. He lost approximately 45% of his total blood volume during surgery. What symptoms would alert the nurse that fluid replacement therapy is inadequate during the immediate postoperative period?
- Arterial pH less than 7.35; central venous pressure (CVP) between 10 and 12 cm H20.
- Arterial pH between 7.35 and 7.45; CVP between 10 and 12 cm H20.
- Arterial pH less than 7.35; CVP less than 5 cm H20.
- Arterial pH greater than 7.45; CVP greater than 12 cm H20.
Correct

#1 is not correct. The person in severe shock will be acidotic, but the central venous pressure will fall. The level in this answer is in the normal range.
#2 is not correct. The person in severe shock will be in acidosis. The pH in this answer is normal. The CVP for the person in severe shock will be low. The CVP in this answer is normal.
#3 is correct. With severe hypovolemic shock, the body ceases aerobic metabolism via the Krebs cycle and begins to metabolize anaerobically. Thus cellular acidosis occurs and the arterial pH would be less than 7.35 The cardiac output decreases due to the blood loss. Since cardiac output equals stroke volume times heart rate, the body will attempt to compensate by tachycardia. The CVP will decrease below the normal of 4-10 cm H20 due to the hypovolemia.
#4 is not correct. The person in severe shock will be in acidosis. The pH in this answer is alkaline. The CVP for the person in severe shock will be low. The CVP in this answer is high.

Incorrect

#1 is not correct. The person in severe shock will be acidotic, but the central venous pressure will fall. The level in this answer is in the normal range.
#2 is not correct. The person in severe shock will be in acidosis. The pH in this answer is normal. The CVP for the person in severe shock will be low. The CVP in this answer is normal.
#3 is correct. With severe hypovolemic shock, the body ceases aerobic metabolism via the Krebs cycle and begins to metabolize anaerobically. Thus cellular acidosis occurs and the arterial pH would be less than 7.35 The cardiac output decreases due to the blood loss. Since cardiac output equals stroke volume times heart rate, the body will attempt to compensate by tachycardia. The CVP will decrease below the normal of 4-10 cm H20 due to the hypovolemia.
#4 is not correct. The person in severe shock will be in acidosis. The pH in this answer is alkaline. The CVP for the person in severe shock will be low. The CVP in this answer is high.
Question 5 of 20

5. Question
Blood gas values for an adult client are pH 7.30; CO2 32; HCO3 16. What additional finding would the nurse be most apt to elicit from the client?
- Long history of lung disease
- Insulin dependent diabetes mellitus
- Several days of vomiting
- Anxiety attack
Correct

#1 is not correct. The blood gas values are suggestive of metabolic acidosis. A long history of lung disease could be a cause of respiratory acidosis.
#2 is correct. The blood gas values are suggestive of metabolic acidosis, which occurs in insulin dependent diabetes mellitus.
#3 is not correct. The blood gas values are suggestive of metabolic acidosis. Several days of vomiting could cause metabolic alkalosis.
#4 is not correct. The blood gas values are suggestive of metabolic acidosis. An anxiety attack might cause hyperventilation and respiratory alkalosis.

Incorrect

#1 is not correct. The blood gas values are suggestive of metabolic acidosis. A long history of lung disease could be a cause of respiratory acidosis.
#2 is correct. The blood gas values are suggestive of metabolic acidosis, which occurs in insulin dependent diabetes mellitus.
#3 is not correct. The blood gas values are suggestive of metabolic acidosis. Several days of vomiting could cause metabolic alkalosis.
#4 is not correct. The blood gas values are suggestive of metabolic acidosis. An anxiety attack might cause hyperventilation and respiratory alkalosis.
Question 6 of 20

6. Question
Blood gas values for an adult client are pH 7.30; CO2 60; HCO3 30. What additional finding would the nurse be most apt to elicit from the client?
- Long history of lung disease
- Insulin dependent diabetes mellitus
- Several days of vomiting
- Anxiety attack
Correct

#1 is correct. The blood gas values are those of respiratory acidosis, which is found in chronic lung disease.
#2 is not correct. Insulin dependent diabetes mellitus can cause metabolic acidosis.
#3 is not correct. Several days of vomiting can cause metabolic alkalosis.
#4 is not correct. An anxiety attack might cause hyperventilation and respiratory alkalosis.

Incorrect

#1 is correct. The blood gas values are those of respiratory acidosis, which is found in chronic lung disease.
#2 is not correct. Insulin dependent diabetes mellitus can cause metabolic acidosis.
#3 is not correct. Several days of vomiting can cause metabolic alkalosis.
#4 is not correct. An anxiety attack might cause hyperventilation and respiratory alkalosis.
Question 7 of 20

7. Question
An adult client has been vomiting for several days. Blood gases are drawn. The nurse would expect to see which of the following lab values?
- pH 7.33; CO2 54; HCO3 30.
- pH 7.33; CO2 32; HCO3 17.
- pH 7.54; CO2 50; HCO3 34.
- pH 7.55; CO2 30; HCO3 22.
Correct

#1 is not correct. These values indicate respiratory acidosis.
#3 is correct. Vomiting causes metabolic alkalosis.
#2 is not correct. These values indicate metabolic acidosis.
#4 is not correct. These values indicate respiratory alkalosis.

Incorrect

#1 is not correct. These values indicate respiratory acidosis.
#3 is correct. Vomiting causes metabolic alkalosis.
#2 is not correct. These values indicate metabolic acidosis.
#4 is not correct. These values indicate respiratory alkalosis.
Question 8 of 20

8. Question
An adult client has had diarrhea for several days. Blood gases are drawn. The nurse would expect to see which of the following lab values?
- pH 7.33; CO2 54; HCO3 30.
- pH 7.33; CO2 32; HCO3 17.
- pH 7.54; CO2 50; HCO3 34.
- pH 7.55; CO2 30; HCO3 22.
Correct

#1 is not correct. These values indicate respiratory acidosis.
#2 is correct. Diarrhea causes metabolic acidosis.
#3 is not correct. These values indicate metabolic alkalosis.
#4 is not correct. These values indicate respiratory alkalosis.

Incorrect

#1 is not correct. These values indicate respiratory acidosis.
#2 is correct. Diarrhea causes metabolic acidosis.
#3 is not correct. These values indicate metabolic alkalosis.
#4 is not correct. These values indicate respiratory alkalosis.
Question 9 of 20

9. Question
An adult had major abdominal surgery this morning under general anesthesia. When the client arrives in the recovery room she is very lethargic and restless. Her BP is 150/98; pulse 110 and irregular; respirations 30 and shallow. Postoperative orders include meperidine (Demerol) 75 mg I.M. for operative site pain; reinforce dressings p.r.n.; O2 @ 6 liters/min p.r.n.; irrigate nasogastric tube q 2 hours and p.r.n.; IV 2500 cc D5W in 24 hours. The nurse assesses the patency of the I.V. The next intervention for the nurse to make is to
- Carefully inspect the dressings for any drainage.
- Irrigate the nasogastric tube.
- Administer meperidine (Demerol) as ordered.
- Administer oxygen.
Correct

#1 is not correct. Oxygen is a higher priority than inspecting the dressing.
#2 is not correct. Oxygen is a higher priority than irrigating the nasogastric tube. There is no data to suggest obstruction of the NG tube.
#3 is not correct. Oxygen is a higher priority than administering pain medication, especially when the data suggest hypoxia.
#4 is correct. This patient who had major surgery under general anesthesia is lethargic and restless and has respiration of 30 and shallow with a pulse of 110. All of these signs suggest hypoxia. Oxygen is the first priority.

Incorrect

#1 is not correct. Oxygen is a higher priority than inspecting the dressing.
#2 is not correct. Oxygen is a higher priority than irrigating the nasogastric tube. There is no data to suggest obstruction of the NG tube.
#3 is not correct. Oxygen is a higher priority than administering pain medication, especially when the data suggest hypoxia.
#4 is correct. This patient who had major surgery under general anesthesia is lethargic and restless and has respiration of 30 and shallow with a pulse of 110. All of these signs suggest hypoxia. Oxygen is the first priority.
Question 10 of 20

10. Question
An adult client who had major abdominal surgery is returned to her room on the surgical nursing unit. The post anesthesia nurse reports that the client is awake, has stable vital signs. She has an NG tube in place, which is attached to intermittent suction. The nurse should position the client in which of the following positions?
- Supine
- Semi-Sitting
- Dorsal Recumbent
- Prone
Correct

#1 is not correct. Supine position would increase the chances of aspiration. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.
#2 is correct. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.
#3 is not correct. Dorsal recumbent would increase the chances of aspiration. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.
#4 is not correct. Prone would increase the chances of aspiration. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.

Incorrect

#1 is not correct. Supine position would increase the chances of aspiration. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.
#2 is correct. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.
#3 is not correct. Dorsal recumbent would increase the chances of aspiration. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.
#4 is not correct. Prone would increase the chances of aspiration. An alert person who has a nasogastric tube in place should be placed in semi-sitting position to prevent aspiration.
Question 11 of 20

11. Question
An adult postoperative client vomits and his abdominal wound eviscerates. What is the best initial action for the nurse to take?
- Cover the exposed coils of intestine with towels moistened with sterile saline.
- Pack the intestines back into the abdominal cavity.
- Irrigate the exposed coils of intestines with sterile saline.
- Increase the IV fluid rate to prevent shock and notify the surgeon.
Correct

#1 is correct. The exposed intestines should be covered with towels or dressings soaked with sterile normal saline.
#2 is not correct. The nurse should not pack the intestines back into the abdominal cavity. The patient will probably go to surgery.
#3 is not correct. Covering the exposed intestinal coils with a sterile saline compress is more appropriate than irrigating.
#4 is not correct. Initially the nurse should cover the exposed intestines with sterile saline dressings. It would be appropriate to have someone else call the physician. The nurse should not initially increase the IV fluid rate.

Incorrect

#1 is correct. The exposed intestines should be covered with towels or dressings soaked with sterile normal saline.
#2 is not correct. The nurse should not pack the intestines back into the abdominal cavity. The patient will probably go to surgery.
#3 is not correct. Covering the exposed intestinal coils with a sterile saline compress is more appropriate than irrigating.
#4 is not correct. Initially the nurse should cover the exposed intestines with sterile saline dressings. It would be appropriate to have someone else call the physician. The nurse should not initially increase the IV fluid rate.
Question 12 of 20

12. Question
Thirty-six hours after major surgery a client has a temperature of 100˚F. What is the most likely cause of the temperature elevation?
- Dehydration
- Atelectasis
- Wound Infection
- Bladder Infection
Correct

#1 is not correct. Dehydration caused low-grade fever is most likely to occur within the first few hours after surgery.
#2 is correct. A fever that onset 24-48 hours after surgery is most likely to be respiratory in nature.
#3 is not correct. It takes at least 72 hours for a wound infection to cause fever.
#4 is not correct. Fever caused by bladder infection is more likely to onset 48-72 hours after surgery.

Incorrect

#1 is not correct. Dehydration caused low-grade fever is most likely to occur within the first few hours after surgery.
#2 is correct. A fever that onset 24-48 hours after surgery is most likely to be respiratory in nature.
#3 is not correct. It takes at least 72 hours for a wound infection to cause fever.
#4 is not correct. Fever caused by bladder infection is more likely to onset 48-72 hours after surgery.
Question 13 of 20

13. Question
A 75-year-old man is brought to the auditory clinic by his son who tells the nurse that his father is having trouble hearing and seems to be a little depressed. The man says, “There’s no point in getting a hearing aid. I don’t have much time left and didn’t use the time I had very well anyway.” The nurse recognizes that this behavior indicates the client may be
- Actively suicidal.
- Suffering from bipolar depression.
- Struggling with generativity Vs stagnation.
- Struggling with integrity Vs despair.
Correct

#1 is not correct. There is no data to suggest that this person is suicidal.
#2 is not correct. There is no data to suggest that this person has bipolar depression.
#3 is not correct. Generativity Vs stagnation is the developmental task for the middle adult.
#4 is correct. Integrity vs. despair is the developmental task of the elderly. This includes looking at one’s life with some satisfaction for what has been accomplished. This client indicates he is not satisfied with his life.

Incorrect

#1 is not correct. There is no data to suggest that this person is suicidal.
#2 is not correct. There is no data to suggest that this person has bipolar depression.
#3 is not correct. Generativity Vs stagnation is the developmental task for the middle adult.
#4 is correct. Integrity vs. despair is the developmental task of the elderly. This includes looking at one’s life with some satisfaction for what has been accomplished. This client indicates he is not satisfied with his life.
Question 14 of 20

14. Question
An 88-year-old woman in a long-term care facility is having difficulty remembering where her room is. Which of the following would best help her?
- Put a light blue painting on the door to her room.
- Assign her a buddy who will help her when she gets lost.
- Put her picture and her name in large letters on the door to her room.
- Assigning her the room next to the nurses' station so the staff can assist her.
Correct

#1 is not correct. Older persons are apt to have difficulty with blue green and pastel colors.
#2 is not correct. It is not necessary to assign her a buddy.
#3 is correct. The behavior suggests short-term memory loss. Identifying her room with her picture, probably a picture of her as a younger woman, and her name in large letters so she can easily read it will help her find her room. Note the client is in a long-term-care facility not an acute care facility.
#4 is not correct. There is not data to indicate it is necessary to put her next to the nurse’s station.

Incorrect

#1 is not correct. Older persons are apt to have difficulty with blue green and pastel colors.
#2 is not correct. It is not necessary to assign her a buddy.
#3 is correct. The behavior suggests short-term memory loss. Identifying her room with her picture, probably a picture of her as a younger woman, and her name in large letters so she can easily read it will help her find her room. Note the client is in a long-term-care facility not an acute care facility.
#4 is not correct. There is not data to indicate it is necessary to put her next to the nurse’s station.
Question 15 of 20

15. Question
The family of an elderly client asks why their father puts so much salt on his food. The nurse should include which information in the response?
- The taste buds become dulled as a person ages.
- The body is attempting to compensate for lost fluids during the aging process.
- Elderly clients need more sodium to ensure adequate kidney function.
- The client is confused and does not remember putting salt on the food.
Correct

#1 is correct. As people age, the taste buds diminish and become dulled. Many elderly persons put large amounts of salt on food.
#2 is not correct. If the client looses fluids, thirst is the response not a desire for more salt.
#3 is not correct. Elderly clients do not need more sodium for renal function or anything else.
#4 is not correct. Confusion could play a role, but the more likely reason is loss of taste sensation.

Incorrect

#1 is correct. As people age, the taste buds diminish and become dulled. Many elderly persons put large amounts of salt on food.
#2 is not correct. If the client looses fluids, thirst is the response not a desire for more salt.
#3 is not correct. Elderly clients do not need more sodium for renal function or anything else.
#4 is not correct. Confusion could play a role, but the more likely reason is loss of taste sensation.
Question 16 of 20

16. Question
A 65-year-old client is seen in an urgent care center for a sprained ankle. The client also tells the nurse, “I don’t know what the problem is. I’m tired all the time. I guess it’s just a sign I’m getting old.” What is the best response for the nurse to make?
- "Sixty five isn't that old. Do you have enough activities to keep you from getting bored?"
- "It's normal for someone your age to feel tired like that. Try taking a 2 hour nap during the day."
- "It's not normal for someone your age to be tired all the time. Have you had a physical exam recently?"
- "You sound depressed. Would you like the name of a psychiatrist?"
Correct

#1 is not correct. Fatigue could be related to boredom but the nurse should not make that assumption.
#2 is not correct. It is not normal for a 65-year-old to be tired all the time.
#3 is correct. It is not normal for a 65 year old to be tired all the time. Chronic fatigue can be a sign of many things including anemia, diabetes, etc. The client should be thoroughly evaluated by a physician.
#4 is not correct. Fatigue could be related to depression but the nurse should not make that assumption. The client should be evaluated for physical illness first.

Incorrect

#1 is not correct. Fatigue could be related to boredom but the nurse should not make that assumption.
#2 is not correct. It is not normal for a 65-year-old to be tired all the time.
#3 is correct. It is not normal for a 65 year old to be tired all the time. Chronic fatigue can be a sign of many things including anemia, diabetes, etc. The client should be thoroughly evaluated by a physician.
#4 is not correct. Fatigue could be related to depression but the nurse should not make that assumption. The client should be evaluated for physical illness first.
Question 17 of 20

17. Question
The nurse is discussing care of a client with a hearing deficit. Which suggestion is most appropriate to make to those around him?
- Speak in a higher tone of voice.
- Raise your voice when speaking.
- Be sure to stand so there are no bright lights behind you.
- Keep the television or radio on when having a conversation.
Correct

#1 is not correct. Persons with hearing deficits usually hear lower tones better so speaking in a higher tone of voice makes it more difficult to hear.
#2 is not correct. Raising the voice tends to raise the pitch and make it more difficult to hear.
#3 is correct. Persons with hearing deficits tend to read lips and faces. Standing with a bright light behind the speaker makes it very difficult to read lips.
#4 is not correct. Background noise makes hearing more difficult.

Incorrect

#1 is not correct. Persons with hearing deficits usually hear lower tones better so speaking in a higher tone of voice makes it more difficult to hear.
#2 is not correct. Raising the voice tends to raise the pitch and make it more difficult to hear.
#3 is correct. Persons with hearing deficits tend to read lips and faces. Standing with a bright light behind the speaker makes it very difficult to read lips.
#4 is not correct. Background noise makes hearing more difficult.
Question 18 of 20

18. Question
An elderly woman is admitted to the hospital with a productive cough, progressive forgetfulness, inability to concentrate and disinterest in her personal hygiene. What should be of greatest priority as the nurse assesses this client?
- Her progressive forgetfulness.
- Her inability to concentrate.
- Her disinterest in her personal hygiene.
- Her productive cough.
Correct

#1 is not correct. Progressive forgetfulness in an elderly person is more likely to be a long-term problem and is not the highest immediate priority.
#2 is not correct. Inability to concentrate in an elderly person is more likely to be a long-term problem and is not the highest immediate priority.
#3 is not correct. Disinterest in personal hygiene in an elderly person is more likely to be a long-term problem and is not the highest immediate priority.
#4 is correct. The highest priority has to be the productive cough. It could signify a problem that needs immediate treatment. The other concerns are longer term and should be addressed after the cough.

Incorrect

#1 is not correct. Progressive forgetfulness in an elderly person is more likely to be a long-term problem and is not the highest immediate priority.
#2 is not correct. Inability to concentrate in an elderly person is more likely to be a long-term problem and is not the highest immediate priority.
#3 is not correct. Disinterest in personal hygiene in an elderly person is more likely to be a long-term problem and is not the highest immediate priority.
#4 is correct. The highest priority has to be the productive cough. It could signify a problem that needs immediate treatment. The other concerns are longer term and should be addressed after the cough.
Question 19 of 20

19. Question
The nurse in a retirement home has noticed that Mr. A. and Ms. C. have been holding hands frequently. One day the nurse enters Mr. A’s room and finds Mr. A. and Ms. C. having sexual intercourse. Both residents are alert and oriented. What is the most appropriate action for the nurse to take?
- Interrupt the couple and send Ms. C. to her room.
- Leave the room and close the door.
- Notify the relatives of both residents.
- Ask Ms. C if she is all right.
Correct

#1 is not correct. The couple appears to be having consensual sex in an appropriate place. There is no need to interrupt.
#2 is correct. Both residents are alert and oriented. A relationship has existed. There is no evidence of force being used. It would appear to be a mutually consenting act. Leave the room and close the door.
#3 is not correct. There is no need to notify the relatives when alert and oriented adults have consensual sex.
#4 is not correct. There is no data to suggest that this is not consensual.

Incorrect

#1 is not correct. The couple appears to be having consensual sex in an appropriate place. There is no need to interrupt.
#2 is correct. Both residents are alert and oriented. A relationship has existed. There is no evidence of force being used. It would appear to be a mutually consenting act. Leave the room and close the door.
#3 is not correct. There is no need to notify the relatives when alert and oriented adults have consensual sex.
#4 is not correct. There is no data to suggest that this is not consensual.
Question 20 of 20

20. Question
A 45 year old tells the nurse that she is having difficulty reading the newspaper. She states she holds it away from her but still cannot see it. What is the best response for the nurse to make?
- Reassure her that this is normal and encourage her to use a magnifying glass.
- Ask her if any of her relatives have had this problem.
- Suggest she see an eye doctor for a prescription for reading glasses.
- Explain that she can try on reading glasses at the drug store.
Correct

#1 is not correct. The data suggest presbyopia – the normal loss of accommodation that occurs with aging. However, prescription glasses can make reading and close work much easier. , There are other eye conditions that occur with aging so the client should be seen by an eye doctor
#2 is not correct. The data suggest presbyopia – the normal loss of accommodation that occurs with aging.
#3 is correct. The data suggest presbyopia – the normal loss of accommodation that occurs with aging. The best response is to suggest the client see an eye doctor for reading glasses.
#4 is not correct. Reading glasses can be purchased at the drug store. However, there are other eye conditions that occur with aging so the client should be seen by an eye doctor. Non-prescription reading glasses are not appropriate for persons if both eyes do not have the same weakness.

Incorrect

#1 is not correct. The data suggest presbyopia – the normal loss of accommodation that occurs with aging. However, prescription glasses can make reading and close work much easier. , There are other eye conditions that occur with aging so the client should be seen by an eye doctor
#2 is not correct. The data suggest presbyopia – the normal loss of accommodation that occurs with aging.
#3 is correct. The data suggest presbyopia – the normal loss of accommodation that occurs with aging. The best response is to suggest the client see an eye doctor for reading glasses.
#4 is not correct. Reading glasses can be purchased at the drug store. However, there are other eye conditions that occur with aging so the client should be seen by an eye doctor. Non-prescription reading glasses are not appropriate for persons if both eyes do not have the same weakness.

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