Question

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Answer 1

Correct Answers:

Restrict head movement.

Rationale :

✅ Prior to surgery for retinal detachment, the client must be instructed to restrict head and eye movement to prevent further retinal separation.

✅ Retinal detachment involves the separation of the retina from the underlying tissue, and any sudden or excessive movement may worsen the detachment or cause additional retinal tearing.

✅ Immobilization helps maintain the retina's position, reducing intraocular pressure and preventing vitreous shifting.

✅ Unlike the application of cool compresses or patching both eyes, head restriction is critical in stabilizing the retina until surgical repair is performed.

✅ Eye drops used in retinal detachment cases typically dilate the pupil (mydriatics) rather than constrict it to facilitate surgical access.

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Answer 2

Correct Answers:

Glucagon treats hypoglycemia resulting from insulin overdose.

Rationale :

🔹Glucagon is an emergency medication used to treat severe hypoglycemia, especially in clients with type 1 diabetes mellitus who are unable to safely consume carbohydrates due to unconsciousness or seizures.

🔹It works by stimulating the liver to convert stored glycogen into glucose, thereby rapidly increasing blood glucose levels.

🔹This is particularly useful in the event of insulin overdose, skipped meals, or increased physical activity without proper insulin adjustment.

🔹 Families of children with diabetes should be taught to administer glucagon intramuscularly or subcutaneously and seek emergency assistance afterward.

🔹 Glucagon is not used to enhance insulin effects or treat lipoatrophy.

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Answer 3

Correct Answers:

The most common cause of a cataract is aging-

Rationale :

🔹Cataracts are characterized by the clouding of the lens, which interferes with light transmission and impairs vision.

🔹The most common cause is the natural aging process, in which lens proteins degrade and clump together, resulting in opacities.

🔹This condition is termed senile cataracts and typically occurs in adults over 60.

🔹Risk factors such as ultraviolet light exposure, smoking, diabetes, and long-term corticosteroid use can accelerate this process.

🔹While trauma or congenital factors may contribute in younger populations, age-related degeneration remains the predominant cause in older adults, and understanding this helps guide prevention and screening.

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Answer 4

Correct Answers:

"It is hypertension with no specific cause!'

Rationale :

◑ Primary hypertension, also referred to as essential hypertension, is diagnosed when no identifiable secondary cause is found.

◑ It accounts for the vast majority (90–95%) of hypertension cases.

◑ This form of hypertension develops gradually due to a combination of genetic predisposition, lifestyle factors (e.g., high sodium intake, obesity, sedentary behavior), and age-related vascular changes.

◑ The term does not imply severity or urgency but rather indicates that it is not caused by another disease, such as renal artery stenosis or endocrine disorders.

◑ Education should focus on lifestyle modifications and long-term pharmacologic control to prevent complications such as stroke, heart failure, and kidney disease.

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Answer 5

Correct Answers:

Take prescribed anti-inflammatory medications with meals.

Rationale :

⇛ Clients with rheumatoid arthritis (RA) are commonly prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids to reduce joint inflammation and improve function.

⇛ These medications are gastric irritants, especially with long-term use, and can lead to gastritis, ulcers, or gastrointestinal bleeding if taken on an empty stomach.

⇛ Clients must be instructed to take these medications with food or milk to reduce the risk of adverse gastrointestinal effects.

⇛ While other options such as alternating hot and cold packs and avoiding high-impact activity are also helpful, NSAID safety is a critical component of medication adherence and long-term therapy effectiveness.

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Answer 6

Correct Answers:

Pruritus

Rationale :

🔹Scabies is a contagious skin condition caused by infestation with the mite Sarcoptes scabiei.

🔹The primary clinical manifestation is intense pruritus (itching), which is especially severe at night.

🔹The itching results from a delayed hypersensitivity reaction to the mites, their eggs, and feces within the skin.

🔹 The rash may present as small papules, burrows, or vesicles, commonly located between the fingers, wrists, elbows, and along the waistline.

🔹Persistent scratching can lead to secondary bacterial infections, particularly in children.

🔹Recognizing pruritus as the hallmark symptom supports early diagnosis and effective treatment with topical scabicides.

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Answer 7

Correct Answers:

Preventing infection of lesions.

Rationale :

💎In infants with eczema (atopic dermatitis), maintaining skin integrity is essential due to the risk of secondary bacterial infection, particularly from scratching open lesions.

💎Preventing infection becomes the top priority, especially in infants with immature immune systems.

💎Nursing interventions include moisturizing the skin, keeping fingernails trimmed, using hypoallergenic products, and monitoring for signs of infection (e.g., pus, increased redness, warmth).

💎Keeping the infant content and ensuring nutrition are also important, but infection control takes priority to prevent complications like cellulitis or systemic infection.

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Answer 8

Correct Answers:

Fatigue. night sweats, and hemoptysis

Rationale :

✔️ The classic clinical presentation of active tuberculosis (TB) includes chronic fatigue, night sweats, low-grade fever, weight loss, and productive cough with possible hemoptysis.

✔️ These symptoms develop gradually and reflect progressive pulmonary involvement caused by Mycobacterium tuberculosis.

✔️ Hemoptysis occurs due to erosion of blood vessels in necrotic lung tissue.

✔️ Night sweats and fatigue result from the chronic inflammatory response.

✔️ Recognizing this constellation of symptoms supports early diagnosis, airborne isolation, and initiation of multidrug antitubercular therapy to prevent spread and complications.

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Answer 9

Correct Answers:

Potassium

Rationale :

🔸Thiazide diuretics, such as hydrochlorothiazide, increase the excretion of sodium, chloride, and potassium in the distal renal tubules.

🔸 This results in potassium depletion, which can cause muscle weakness, fatigue, and potentially fatal cardiac arrhythmias.

🔸Therefore, clients are advised to consume potassium-rich foods (e.g., bananas, oranges, spinach) or may be prescribed potassium supplements.

🔸Unlike loop diuretics, thiazides may slightly increase calcium levels, and there is no significant loss of sodium or magnesium to warrant supplementation unless otherwise indicated.

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Answer 10

Correct Answers:

Apply a thin layer of cream and rub it into the area thoroughly.

Rationale :

✔️Topical corticosteroids are prescribed to reduce inflammation in conditions like contact dermatitis, but must be used judiciously in children due to increased percutaneous absorption and potential systemic effects.

✔️ Parents should be instructed to apply a thin layer only to the affected area, and to gently rub it in until absorbed.

✔️ Overuse or application to large areas can lead to side effects like skin atrophy, pigmentation changes, or adrenal suppression.

✔️ Cleansing the area before application is generally recommended, and the medication should not be applied thickly or to unaffected skin.

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RN ATI Medsurg Nur 211 Final Exam

No.

1 : A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

2 : A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?

3 : An older adult patient asks the nurse what caused his cataract. The nurse's response is based on which information?

4 : A student nurse asks what "primary hypertension" is. What response by the registered nurse is best?

5 : Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?

6 : What is the primary clinical manifestation in a child with scabies?

7 : The nurse is planning nursing care for a 3-month-old infant with eczema. What would be considered a priority intervention for this client?

8 : A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited?

9 : When teaching a patient who is taking thiazide diuretics, the nurse will encourage the patient to increase the intake of which electrolyte?

10 : A topical corticosteroid is prescribed by the primary health care provider for a child with contact dermatitis. Which instruction should the nurse give the parent about applying the cream?

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