Nokea
A young man was swimming at the beach when an exceptionally large wave caused him to be drawn under the water. His family members found him in the water and pulled him ashore. He states that he heard something snap in his neck. When a nurse arrives, he is conscious and lying on his back. He states that he has no pain. He is unable to move his legs. How should he be transported?
- A. Position him in a prone position and place on a backboard.
- B. Apply a neck collar and position supine on a backboard.
- C. Log roll him to a rigid backboard.
- D. Position in an upright position with a firm neck collar.
Correct Answer: B
Rationale: A suspected neck injury requires immobilization with a neck collar and supine positioning on a backboard to prevent further spinal cord damage.
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The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first?
- A. Teach the signs of increased intraocular pressure.
- B. Position the client as prescribed by the surgeon.
- C. Assess the eye for signs/symptoms of complications.
- D. Explain the importance of follow-up visits.
Correct Answer: B
Rationale: Positioning as prescribed (e.g., face-down) is critical to maintain gas tamponade efficacy and retinal reattachment. Teaching, assessment, and follow-up are secondary.
A cataract extraction is performed on a client's right eye. What is the priority nursing care immediately postoperative?
- A. Assist her to turn, cough, and deep breathe every two hours.
- B. Keep her NPO for four hours.
- C. Assist her in moving her arms and legs in ROM.
- D. Position client on her right side.
Correct Answer: C
Rationale: Assisting with range of motion prevents complications like stiffness while avoiding strain on the surgical eye.
The client is receiving treatment with gentamicin ophthalmic solution for bacterial conjunctivitis. Which symptom, described by the client, indicates that the medication is ineffective?
- A. Eyes feel strained
- B. Yellowish eye drainage
- C. Twitching of the eye
- D. Unable to read small print
Correct Answer: B
Rationale: Mucopurulent eye drainage, especially yellowish or greenish, is associated with bacterial conjunctivitis; continuing with eye drainage indicates gentamicin is ineffective in treating the infection. Eyestrain, twitching, and inability to read small print are not associated with an infectious process.
The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test?
- A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis.
- B. This is of diagnostic value in only 25% of patients with myasthenia gravis.
- C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis.
- D. Tensilon works by blocking the action of acetylcholine at the myoneural junction.
Correct Answer: A
Rationale: A positive Tensilon test shows increased muscle strength within one minute, confirming myasthenia gravis, as Tensilon enhances acetylcholine activity.
The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client's chart?
- A. Complaints of vertigo.
- B. Complaints of otorrhea.
- C. Complaints of tinnitus.
- D. Complaints of presbycusis.
Correct Answer: C
Rationale: Ringing in the ears is tinnitus, the appropriate term to document. Vertigo, otorrhea, and presbycusis (age-related hearing loss) are distinct symptoms.