NCLEX Section 6 - Physiological Integrity COMPLETE REVISION
QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
ANSWERS) ALREADY GRADED
While completing a nursing assessment, the client states he is 70 years old, has a history of staphylococcus infections, increased intraocular pressure, and blurry vision. The nurse concludes that which item reported by the client is a risk factor for the development of cataracts?
- History of staphylococcus infections
- Increased intraocular pressure
- Stated age of client
- Long complaint of blurry vision - Answer: Answer: 3 Rationale: Age above 65 is a risk factor for
- Speak louder into the client's ear determined to have better hearing.
- Lower the pitch of the voice and face the client during the interview.
- Put new batteries in the hearing aid to ensure proper functioning. - Answer: Answer: 3 Rationale:
cataracts. Double vision, increased intraocular pressure, and blurry vision are signs of glaucoma.A 92-year-old client is in the hospital. The client is very hard of hearing, and the nurse needs to do the admission interview. Which action is appropriate for the nurse when assessing the client?
1.Use a cotton swab to clean cerumen in the client's ear before the interview.
Hearing loss, especially of upper-range tones, is common in the elderly. Speaking to the client slowly and in a lower-pitched voice while facing the client is the best means of communication. Cleaning cerumen from the client's ears will not overcome age-related hear- ing loss. Depending on the level of hearing loss, speaking louder into the ear with the better hearing may still not be an effective action. The question states that the client is hard of hearing without reference to a hearing aid; if a hearing aid is used, changing the batteries may not be an effective action. 1 / 2
A 72-year-old client has been in the ICU for the past 2 days. Which intervention would be the most appropriate in decreasing the risk for sensory deprivation? Select all that apply.
1.Remove equipment from the room.
- Explain procedures and routines to the client upon admission.
- Provide a clock and calendar in the client's room.
- Maintain a balance of activity and rest periods.
- Maintain constant conversation when in the client's room. - Answer: Answer: 3, 4 Rationale: Providing
- Wrap the extremity loosely enough to insert two fingers beneath the bandage.
- Maintain a tight stretch with each wrap of the bandage.
- Start proximal to the injury site and work distally. - Answer: Answer: 1 Rationale: To prevent vascular
- Laceration from broken glass in a 6-year-old client 3. Stab wound in the arm of a 37-year-old client
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the client with a clock and calendar helps the client to be oriented to time and date. These would be meaningful stimuli for the client and decrease the chance for sensory deprivation. Activities and rest periods should be spaced and planned to balance high and low levels of sensory stimuli. It may not be realistic in an ICU to remove equipment from the room. Explaining all procedures and routines would increase the risk of overload. Continuous conversation is not therapeutic and could place the client at risk for sensory overload as a different problem.The nurse must apply an elastic bandage to support a client's sprained ankle. Which action should the nurse take during this procedure?
1.Moderately stretch the bandage and wrap it from distal extremity to proximal.
impairment, proper application of elastic bandages is required. Wrapping distal to proximal is compatible with the flow of venous return. Wrapping the bandage evenly while stretching it moderately ensures that there will be even tension applied to the extremity while not occluding circulation.Wrapping the ban- dage loosely enough to be able to insert two fingers will not secure the bandage in place or provide adequate support for the injury. Excessive tension when applying an elastic ban- dage would cause circulation to be compromised. W All of the following clients appear in the emergency room during one shift. For which clients should the nurse expect the health care provider to order an antibiotic? Select all that apply.
1.Cat bite to the hand of an elderly client