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A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?
- A. Explain the location of items using clock cues.
- B. Explain that each of the items on the tray is clearly separated.
- C. Describe the location of items from the bottom of the plate to the top.
- D. Ask the patient to describe the location of items before confirming their location.
Correct Answer: A
Rationale: Clock cues (e.g., meat at 3 o'clock) effectively orient a visually impaired patient to tray items. Separation, top-to-bottom descriptions, or patient guesses are less practical.
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A patients ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patients discharge education?
- A. Disturbed body image
- B. Chronic pain
- C. Ineffective protection
- D. Unilateral neglect
Correct Answer: A
Rationale: Enucleation and prosthesis use significantly impact body image. Chronic pain, ineffective protection, and unilateral neglect are not typically associated with this procedure.
The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?
- A. Provide instructions in simple, clear terms.
- B. Introduce herself in a firm, loud voice at the doorway of the room.
- C. Lightly touch the patients arm and then introduce herself.
- D. State her name and role immediately after entering the patients room.
Correct Answer: D
Rationale: Stating name and role first identifies the nurse without startling the blind patient. Simplifying instructions or using a loud voice is unnecessary, and touching before introducing may cause discomfort.
A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child?
- A. Handwashing can prevent the spread of the disease to others.
- B. The importance of compliance with antibiotic therapy
- C. Signs and symptoms of complications, such as meningitis and septicemia
- D. The likely need for surgery to prevent scarring of the conjunctiva
Correct Answer: A
Rationale: Viral conjunctivitis is highly contagious, and handwashing prevents spread. Antibiotics are ineffective, meningitis is not a risk, and surgery is not indicated.
A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patients medication regimen. The patient states that she is eager to beat this disease and looks forward to the time that she will no longer require medication. How should the nurse best respond?
- A. You have a great attitude. This will likely shorten the amount of time that you need medications.
- B. In fact, glaucoma usually requires lifelong treatment with medications.
- C. Most people are treated until their intraocular pressure goes below 50 mm Hg.
- D. You can likely expect a minimum of 6 months of treatment.
Correct Answer: B
Rationale: Glaucoma typically requires lifelong medication to manage intraocular pressure. Normal pressure is 10-21 mm Hg, and treatment duration is not limited to 6 months.
The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often?
- A. At least monthly
- B. At least once every 2 years
- C. At least once every 5 years
- D. At least once every 10 years
Correct Answer: B
Rationale: Glaucoma's familial tendency warrants family screening every 2 years for early detection. Monthly exams are excessive, and 5- or 10-year intervals may miss early signs.