Nokea
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.
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The nurse is caring for a client diagnosed with acute otitis media. Which signs/symptoms support this medical diagnosis?
- A. Unilateral pain in the ear.
- B. Green, foul-smelling drainage.
- C. Sensation of congestion in the ear.
- D. Reports of hearing loss.
Correct Answer: A
Rationale: Unilateral ear pain is a primary symptom of acute otitis media. Foul drainage suggests chronic infection, congestion is non-specific, and hearing loss is less common acutely.
An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
- A. Increased cerebral blood flow
- B. Respiratory depression
- C. Increased intracranial pressure
- D. Hyperoxygenation of the cerebrum
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.
Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?
- A. Suggest installing multiple smoke alarms in the home.
- B. Recommend using a night-light in the hallway and bathroom.
- C. Discuss keeping a high-humidity atmosphere in the bedroom.
- D. Encourage the client to smell food prior to eating it.
Correct Answer: A
Rationale: Olfactory decline reduces smoke detection, making multiple smoke alarms critical for safety. Night-lights address vision, humidity is unrelated, and smelling food is unreliable.
The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching?
- A. The client must lie flat with the face down.
- B. The head of the bed must be elevated 45 degrees.
- C. The client should wear sunglasses when outside.
- D. The client should avoid reading for three (3) weeks.
Correct Answer: A
Rationale: Face-down positioning maintains gas tamponade pressure on the retina, aiding reattachment. Elevation, sunglasses, and reading restrictions are secondary or incorrect.
The employee health nurse is teaching a class on 'Preventing Eye Injury.' Which information should be discussed in the class?
- A. Read instructions thoroughly before using tools and working with chemicals.
- B. Wear some type of glasses when working around flying fragments.
- C. Always wear a protective helmet with eye shield around dust particles.
- D. Pay close attention to the surroundings so eye injuries will be prevented.
Correct Answer: A
Rationale: Reading instructions ensures safe tool and chemical use, preventing eye injuries. Glasses are specific, helmets are not always required, and attention is vague.