Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse should plan to monitor the client for which of the following?
A. Widened peripheral vision.
Widened peripheral vision. This choice is not an expected change in an older adult's vision. As individuals age, peripheral vision may diminish, but it doesn't typically widen. Therefore, this choice is not appropriate.
B. Increase in accommodation to near vision.
Increase in accommodation to near vision. This is the correct answer because it is a common age-related change in vision known as presbyopia. As individuals age, their ability to accommodate or focus on near objects diminishes. This change typically begins in the early 40s and progresses over time. It's a result of the lens of the eye becoming less flexible. Older adults may need reading glasses or bifocals to improve their near vision. The nurse should plan to monitor for this change as part of routine care for an older adult.
C. Eyes with large pupils.
Eyes with large pupils. Older adults often experience changes in the size of their pupils due to the aging process. Pupils may become smaller and less responsive to light, not larger. Thus, this choice is not accurate.
D. Infections of the eye.
Infections of the eye. While eye infections can occur in any age group, there's no specific reason to monitor an older adult for eye infections unless there are signs or symptoms suggesting an issue. It's not a routine aspect of care for older adults. Now, let's discuss the rationale for the correct answer, choice B:
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NSG 240 Final Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Widened peripheral vision. This choice is not an expected change in an older adult's vision. As individuals age, peripheral vision may diminish, but it doesn't typically widen. Therefore, this choice is not appropriate.
Choice C rationale:
Eyes with large pupils. Older adults often experience changes in the size of their pupils due to the aging process. Pupils may become smaller and less responsive to light, not larger. Thus, this choice is not accurate.
Choice D rationale:
Infections of the eye. While eye infections can occur in any age group, there's no specific reason to monitor an older adult for eye infections unless there are signs or symptoms suggesting an issue. It's not a routine aspect of care for older adults. Now, let's discuss the rationale for the correct answer, choice B:
Choice B rationale:
Increase in accommodation to near vision. This is the correct answer because it is a common age-related change in vision known as presbyopia. As individuals age, their ability to accommodate or focus on near objects diminishes. This change typically begins in the early 40s and progresses over time. It's a result of the lens of the eye becoming less flexible. Older adults may need reading glasses or bifocals to improve their near vision. The nurse should plan to monitor for this change as part of routine care for an older adult.
Similar Questions
A nurse is preparing to obtain a 24-hr urine collection from a client.
Which of the following actions should the nurse plan to take?
A. Discard the client's last void at the end of the collection time period.
Discard the client's last void at the end of the collection time period. This choice is not appropriate. When conducting a 24-hour urine collection, it's essential to include all urine produced during the specified time frame. Discarding the last void would result in an incomplete and inaccurate collection.
B. Include toilet paper with the collected urine.
Include toilet paper with the collected urine. This choice is also incorrect. Toilet paper is not typically included in a 24-hour urine collection. The purpose of this collection is to accurately measure substances excreted by the kidneys over a specific time period. Toilet paper is not part of this measurement and should not be included.
C. Save the first void at the start of the collection time period.
The first void at the beginning of the collection period is typically discarded, as it represents the urine that was in the bladder before the timed collection started. This helps ensure that the collection is accurate and only includes urine produced during the specified 24-hour period. It's important to follow this protocol to obtain reliable test results.
D. Refrigerate the urine during the collection time period.
Refrigerate the urine during the collection time period. This choice is accurate. When collecting a 24-hour urine sample, it is crucial to refrigerate the urine during the collection period. This helps prevent the breakdown of certain substances and ensures the sample's accuracy. Failure to refrigerate the urine can lead to inaccurate test results. Now, let's discuss the rationale for the correct answer, choice C:
Full Explanation
Choice A rationale:
Discard the client's last void at the end of the collection time period. This choice is not appropriate. When conducting a 24-hour urine collection, it's essential to include all urine produced during the specified time frame. Discarding the last void would result in an incomplete and inaccurate collection.
Choice B rationale:
Include toilet paper with the collected urine. This choice is also incorrect. Toilet paper is not typically included in a 24-hour urine collection. The purpose of this collection is to accurately measure substances excreted by the kidneys over a specific time period. Toilet paper is not part of this measurement and should not be included.
Choice D rationale:
This helps prevent the breakdown of certain substances and ensures the sample's accuracy. Failure to refrigerate the urine can lead to inaccurate test results. Now, let's discuss the rationale for the correct answer, choice C:
Choice C rationale:
The first void at the beginning of the collection period is typically discarded, as it represents the urine that was in the bladder before the timed collection started. This helps ensure that the collection is accurate and only includes urine produced during the specified 24-hour period. It's important to follow this protocol to obtain reliable test results.
A nurse is caring for a client who is at the end of life.
The client's partner is concerned about using opioid narcotics to manage the client's pain.
Which of the following statements should the nurse make?
A. "Opioid narcotics are restricted for the client because of the risk for addiction.”.
"Opioid narcotics are restricted for the client because of the risk for addiction.”. This statement is not accurate. Opioid narcotics are not restricted solely due to the risk of addiction. While there is a potential for addiction with opioids, they are still an essential and effective option for managing severe pain, including end-of-life pain. The key is to use them judiciously and monitor for signs of addiction.
B. "Using opioid narcotics will limit options available for future management of pain.”.
"Using opioid narcotics will limit options available for future management of pain.” Using opioids does not limit future pain management options.
C. "The use of opioid narcotics is restricted to when death is imminent.”.
"The use of opioid narcotics is restricted to when death is imminent.”. This statement is not accurate either. Opioid narcotics can be used to manage severe pain in various situations, not just when death is imminent. They are not restricted to end-of-life care only.
D. "The dosage of the opioid narcotic is unlimited.”. .
"The dosage of the opioid narcotic is unlimited.”. The dosage of opioid narcotics can be increased as needed to manage pain effectively. There is no strict limit, and the goal is to provide adequate pain relief.
Full Explanation
Choice A rationale:
"Opioid narcotics are restricted for the client because of the risk for addiction.”. This statement is not accurate. Opioid narcotics are not restricted solely due to the risk of addiction. While there is a potential for addiction with opioids, they are still an essential and effective option for managing severe pain, including end-of-life pain. The key is to use them judiciously and monitor for signs of addiction.
Choice B rationale;
"Using opioid narcotics will limit options available for future management of pain.” Using opioids does not limit future pain management options.
Choice C rationale:
"The use of opioid narcotics is restricted to when death is imminent.”. This statement is not accurate either. Opioid narcotics can be used to manage severe pain in various situations, not just when death is imminent. They are not restricted to end-of-life care only.
Choice D rationale:
"The dosage of the opioid narcotic is unlimited.”. The dosage of opioid narcotics can be increased as needed to manage pain effectively. There is no strict limit, and the goal is to provide adequate pain relief.
A nurse is performing a blood pressure screening for a client who has a family history of hypertension.
Which of the following concepts is the nurse demonstrating?
A. Disease prevention.
The nurse is demonstrating the concept of disease prevention during a blood pressure screening for a client with a family history of hypertension. Disease prevention involves actions taken to reduce the risk of developing a disease or condition. In this case, the nurse is actively screening for hypertension, a condition that the client may be at risk for due to their family history. By identifying elevated blood pressure early, the nurse can help prevent the progression of hypertension and its associated complications.
B. Holistic health.
Holistic health is a comprehensive approach to healthcare that considers the physical, emotional, social, and spiritual aspects of an individual. While holistic health is an essential aspect of nursing care, the scenario described in the question focuses on a specific action related to blood pressure screening, which is better categorized as disease prevention.
C. Health promotion.
Health promotion involves activities that aim to enhance a person's well-being and quality of life, such as encouraging healthy behaviors and lifestyle choices. While blood pressure screening can be a part of health promotion, the primary goal in the scenario is to identify and prevent hypertension, which aligns more with disease prevention.
D. Health education.
Health education refers to the process of providing information and education to individuals to help them make informed decisions about their health. While health education may be a part of the overall nursing care provided to the client, the primary action in the scenario is to perform a blood pressure screening, which is a proactive measure to prevent disease, rather than solely focused on educating the client.
Full Explanation
Choice A rationale:
The nurse is demonstrating the concept of disease prevention during a blood pressure screening for a client with a family history of hypertension. Disease prevention involves actions taken to reduce the risk of developing a disease or condition. In this case, the nurse is actively screening for hypertension, a condition that the client may be at risk for due to their family history. By identifying elevated blood pressure early, the nurse can help prevent the progression of hypertension and its associated complications.
Choice B rationale:
Holistic health is a comprehensive approach to healthcare that considers the physical, emotional, social, and spiritual aspects of an individual. While holistic health is an essential aspect of nursing care, the scenario described in the question focuses on a specific action related to blood pressure screening, which is better categorized as disease prevention.
Choice C rationale:
Health promotion involves activities that aim to enhance a person's well-being and quality of life, such as encouraging healthy behaviors and lifestyle choices. While blood pressure screening can be a part of health promotion, the primary goal in the scenario is to identify and prevent hypertension, which aligns more with disease prevention.
Choice D rationale:
Health education refers to the process of providing information and education to individuals to help them make informed decisions about their health. While health education may be a part of the overall nursing care provided to the client, the primary action in the scenario is to perform a blood pressure screening, which is a proactive measure to prevent disease, rather than solely focused on educating the client.