Nokea
A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there's something in it. What should the nurse do before taking him to the emergency room?
- A. Thoroughly examine his eyes
- B. Put a pressure dressing on his right eye.
- C. Cover both eyes lightly with gauze
- D. Flush his right eye with water for 20 minutes
Correct Answer: C
Rationale: Covering both eyes lightly with gauze prevents tracking and further injury, suitable for a suspected foreign body until emergency evaluation.
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The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching?
- A. Instruct the client not to take any over-the-counter pain medication.
- B. Encourage the client to apply cold packs to the affected ear.
- C. Tell the client to call the HCP if an abrupt relief of ear pain occurs.
- D. Wear a protective ear plug in the affected ear.
Correct Answer: C
Rationale: Abrupt pain relief in otitis media may indicate tympanic membrane rupture, requiring HCP notification. OTC pain meds are safe, cold packs are less effective, and ear plugs are unnecessary.
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.
Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply.
- A. Perforation of the tympanic membrane.
- B. Chronic exposure to loud noises.
- C. Recurrent ear infections.
- D. Use of nephrotoxic medications.
- E. Multiple piercings in the auricle.
Correct Answer: A,B,C,D
Rationale: Tympanic perforation, loud noise, ear infections, and ototoxic medications (e.g., aminoglycosides) cause hearing loss. Auricle piercings are cosmetic and unrelated.
Which of the following would not be included in the nursing care plan for a client with Parkinson's disease?
- A. Restricting his intake of oral fluids
- B. Range of motion exercises
- C. Allowing him to carry out activities of daily living by himself even though he is very slow
- D. Providing him with diversionary tasks that require motor coordination of hands
Correct Answer: A
Rationale: Fluids should be encouraged to prevent dehydration and manage drooling in Parkinson's disease, making restriction inappropriate.
The nurse is reviewing home management strategies with the client who has dry macular degeneration. The nurse should review using which objects with the client? Select all that apply.
- A. Protective goggles
- B. Lighting that is bright
- C. An Amsler grid
- D. A soft eye patch
- E. Magnification device
Correct Answer: B,C,E
Rationale: The nurse should review using bright lighting because it improves vision and promotes safety. An Amsler grid monitors for sudden onset or distortion of vision, indicating worsening macular degeneration. Magnification devices decrease eyestrain and promote safety. Protective goggles and eye patches are not specifically related to macular degeneration.