Client Needs: Health Promotion and MaintenanceIntegrated Process: Teaching/LearningContent Area: Maternity/AntepartumReference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005).
(2nd ed.). St. Louis: Elsevier, p. 275.905. A nurse is reviewing the results of an eye examination on a client and notes thatresults from the tonometry test indicate an intraocular pressure of 20 mm Hg. The nurseinterprets these findings as:1. Elevated intraocular pressure2. Low intraocular pressure3. Inconclusive findings4. Normal intraocular pressureAnswer: 4Rationale: Tonometry is an effective screening test for early detection of glaucoma. Thenormal intraocular pressure is 12 to 22 mm Hg. An intraocular pressure of 20 mm Hg isa normal finding.Test-Taking Strategy: Knowledge regarding the normal intraocular pressure is requiredto answer this question. Remember that the normal intraocular pressure is 12 to 22 mmHg. If you are unfamiliar with this finding, review this content.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Adult Health/EyeReference: Christensen, B., & Kockrow, E. (2003).
Adult health nursing
(4th ed.). St.Louis: Mosby, p. 562.906. A client has impetigo, and the nurse reviews the home care instructions with theclient. Which statement indicates that the client does not understand the measures thatwill prevent the spread of the infection?1. “I need to take the full course of the antibiotics.”2. “I need to wash my dishes and eating utensils separate from other householdmembers.”3. “My clothes can be laundered with other household members’ clothes.”4. “I must wash my hands thoroughly and frequently throughout the day.”Answer: 3Rationale: It is necessary to separate laundry from other household members. Thoroughhand washing, separating laundry, and separate washing of the client’s dishes are required because the infection is contagious as long as skin lesions are present. Antibiotics areadministered and should be continued as prescribed.Test-Taking Strategy: Note the key words
does not understand
in the stem of thequestion. These words indicate a false-response question and that you need to select theincorrect client statement. General principles related to the administration of antibioticswill assist in eliminating option 1. Knowledge of the principles related to asepsis willassist in eliminating option 4. From the remaining options, recalling that impetigo iscontagious will direct you to option 3. Review home care instructions related to this