Nokea
Which situation makes the nurse suspect the client has glaucoma?
- A. An automobile accident because the client did not see the car in the next lane.
- B. The cake tasted funny because the client could not read the recipe.
- C. The client has been wearing mismatched clothes and socks.
- D. The client ran a stoplight and hit a pedestrian walking in the crosswalk.
Correct Answer: A
Rationale: Not seeing a car in the next lane suggests peripheral vision loss, a hallmark of glaucoma. Taste, color perception, and stoplight issues are unrelated.
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The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
- A. Do not push or pull objects heavier than 50 pounds.
- B. Lie on the affected eye with two pillows at night.
- C. Wear glasses or metal eye shields at all times.
- D. Bend and stoop carefully for the rest of your life.
Correct Answer: C
Rationale: Wearing eye shields protects the eye post-cataract surgery, especially at night. Heavy lifting is restricted lighter, lying on the affected eye is avoided, and lifelong bending restrictions are excessive.
The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse?
- A. The client is ambulating without assistance.
- B. The client is sneezing with the mouth open.
- C. There is some slight serosanguineous drainage.
- D. The client reports hearing popping in the affected ear.
Correct Answer: A
Rationale: Ambulating without assistance post-stapedectomy risks vertigo and falls, requiring intervention. Open-mouth sneezing, slight drainage, and popping are expected.
The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client?
- A. Administer dilating drops to both eyes for 72 hours prior to surgery.
- B. Prior to surgery do not lift or push any objects heavier than 15 pounds.
- C. Make arrangements for being in the hospital for at least three (3) days.
- D. Avoid taking any type of medication which may cause bleeding, such as aspirin.
Correct Answer: D
Rationale: Avoiding bleeding-risk medications like aspirin prevents intraoperative hemorrhage. Dilating drops are not used for 72 hours, lifting restrictions are postoperative, and cataract surgery is typically outpatient.
The client asks the nurse about symptoms associated with retinal detachment. Which symptoms should the nurse identify? Select all that apply.
- A. Seeing bright flashes of light
- B. Shooting, throbbing eye pain
- C. Severe frontal headache
- D. Diminished visual acuity
- E. Seeing floating dark spots in the vision field
Correct Answer: A,D,E
Rationale: As the choroid and retina partially separate, the client notices flashes of light, decreased vision, and floating dark spots. Pain is not associated with retinal detachment due to few pain fibers in the retina. Headache is not associated with retinal detachment.
The client's daughter tells the nurse of frustration while communicating with her elderly mother who wears hearing aids. Which intervention should the nurse suggest to the client's daughter?
- A. Minimize oral communication to essential matters.
- B. Speak directly into her mother's better ear.
- C. Use exaggerated mouth expressions while speaking.
- D. Attract her mother's attention before speaking.
Correct Answer: D
Rationale: Attracting the client's attention improves communication by including the client fully from the start. Minimizing communication, speaking into the ear, or exaggerated expressions are less effective.