Nokea
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.
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A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
- A. Application of topical antibiotic ointment
- B. Maintenance of a supine position for the first 48 hours postoperative
- C. Fluid restriction to prevent orbital edema
- D. Administration of loop diuretics to prevent orbital edema
- E. Use of an ocular pressure dressing
Correct Answer: A,E
Rationale: Post-enucleation care includes topical antibiotic ointment and an ocular pressure dressing to prevent infection and support healing. Supine positioning, fluid restriction, and diuretics are not indicated.
A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond?
- A. Overuse of these drops could soften your cornea and damage your eye.
- B. You could lose the peripheral vision in your eye if you used these drops too much.
- C. Im sorry, this medication is considered a controlled substance and patients cannot take it home.
- D. I know these drops will make your eye feel better, but I cant let you take them home.
Correct Answer: A
Rationale: Topical anesthetics can soften the cornea with overuse, risking permanent damage. They are not controlled substances, and peripheral vision loss is not a primary concern.
During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
- A. Ask the social worker to investigate alternative housing arrangements.
- B. Ask the social worker to investigate community support agencies.
- C. Encourage the patient to explore surgical corrections for the vision problem.
- D. Arrange for referral to a rehabilitation facility for vision training.
Correct Answer: B
Rationale: Community support agencies provide low-vision aids and training for medication management. Housing changes or rehabilitation facilities are excessive, and surgical options may not be applicable.
A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurses initial intervention for this patient?
- A. Generously flush the affected eye with a dilute antibiotic solution.
- B. Generously flush the affected eye with normal saline or water.
- C. Apply a patch to the affected eye.
- D. Apply direct pressure to the affected eye.
Correct Answer: B
Rationale: Immediate irrigation with saline or water flushes chemicals from the eye, minimizing damage. Antibiotics, patching, or pressure are inappropriate initial actions.
The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye?
- A. 30 seconds
- B. 1 minute
- C. 3 minutes
- D. 5 minutes
Correct Answer: D
Rationale: A 5-minute wait ensures adequate absorption of the first eye drop before administering the second, preventing dilution or reduced efficacy.