In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?

Mild headaches

Cloudiness that worsens at night

Severe eye pain

Mild eye pain

Answer and Explanation

The Correct Answer is C

Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.

Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.

Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.

Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.

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Correct Answer is C

Explanation

Choice A reason: Limiting fluid intake in the evening may reduce the need to urinate at night but does not address the client's fear of falling. It is more important to provide a safer alternative for nighttime voiding.

Choice B reason: Putting the side rails up and instructing the client to call the nurse before voiding may help, but it does not provide the most immediate and practical solution. A bedside commode offers a safer and more accessible option.

Choice C reason: Obtaining a bedside commode for the client's use directly addresses the client's concern about falling. It allows the client to void safely without having to walk to the bathroom at night, reducing the risk of falls.

Choice D reason: Leaving a nightlight on in the room can help improve visibility but does not completely eliminate the risk of falling. A bedside commode is a more effective solution.

A. Hyperkalemia. B. Increased glomerular filtration rate (GFR). C. Decreased creatinine level. D. Hypovolemia.

Correct Answer is A

Explanation

Choice A reason: Hyperkalemia is a common finding in the oliguric phase of acute kidney injury due to reduced excretion of potassium by the kidneys. This electrolyte imbalance can have serious cardiac effects and should be expected and monitored in these patients.

Choice B reason: An increased glomerular filtration rate (GFR) would not be expected in the oliguric phase of acute kidney injury. Typically, GFR is decreased due to reduced kidney function during this phase.

Choice C reason: Decreased creatinine levels are not expected in acute kidney injury. Creatinine levels usually increase as kidney function declines and the body cannot adequately filter waste.

Choice D reason: Hypovolemia is not typically expected in the oliguric phase of acute kidney injury, as oliguria (reduced urine output) often indicates fluid retention rather than fluid loss.

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In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse in the med-surgical ICU is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is providing education for a client who has glaucoma. Which statement should the nurse include in the teaching?

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A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

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The nurse is teaching a client with newly diagnosed asthma. Which instructions should the nurse include to reduce the likelihood of an asthma attack? (Select all that apply)

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