Nokea
A family member of the client undergoing cataract surgery asks the nurse if there are ways to prevent cataracts. Which recommendations should the nurse suggest? Select all that apply.
- A. Wear sunglasses that limit ultraviolet light penetration.
- B. Wear sunscreen with a high protection factor number.
- C. Wear eye protection if there is any risk for eye injury.
- D. Avoid activities and reading in dimly lit environments.
- E. Eat foods that are high in vitamin C, such as oranges.
Correct Answer: A,C
Rationale: Limiting eye exposure to UV light has been found to decrease the risk for cataracts. Avoiding trauma to the eye has been found to decrease the risk for cataracts. Sunscreen is applied to the skin, not the eyes. Straining the eyes to read does not lead to cataract formation. There is no evidence that nutrition prevents or delays progression of cataracts.
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Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma?
- A. Incapacitating vertigo and otorrhea.
- B. Nystagmus and complaints of dizziness.
- C. Nausea and vomiting.
- D. Unilateral hearing loss and tinnitus.
Correct Answer: D
Rationale: Acoustic neuroma (vestibular schwannoma) causes unilateral hearing loss and tinnitus due to cranial nerve VIII compression. Vertigo, nystagmus, and nausea are less prominent; otorrhea is unrelated.
The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client's discharge from day surgery?
- A. Wear bilateral eye patches for three (3) days.
- B. Wear corrective lenses until the follow-up visit.
- C. Do not read any material for at least one (1) week.
- D. Teach the client how to instill corticosteroid ophthalmic drops.
Correct Answer: D
Rationale: Corticosteroid drops reduce inflammation post-LASIK, requiring teaching. Eye patches are not used, corrective lenses are unnecessary, and reading restrictions are shorter.
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.
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician's orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, 'I can't believe I really had a seizure. My mom says she was in the room when it happened, but I don't even remember it.' What is the best interpretation of his comments?
- A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
- B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
- C. Inability to remember the seizure is a normal response of a person who has had a seizure.
- D. They are an indication that he would rather not talk about his seizure at this time.
Correct Answer: C
Rationale: Amnesia for the seizure event is a normal response due to altered consciousness during a generalized seizure.
The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include?
- A. Limit oral fluid intake to 1000 mL daily.
- B. Eat foods that are high in omega-3 fatty acids.
- C. Have annual eye exams with an eye specialist.
- D. Use timolol maleate eye drops when feeling eye pressure.
Correct Answer: C
Rationale: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction and omega-3 fatty acids do not affect intraocular pressure. Elevated intraocular pressure cannot be felt, and timolol maleate should be used as prescribed.