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An adult is being treated with phenytoin (Dilantin) for a seizure disorder. Five days after starting the medication, he tells the nurse that his urine is reddish-brown in color. What action should the nurse take?
- A. Inform him that this is a common side effect of phenytoin (Dilantin) therapy
- B. Test the urine for occult blood
- C. Report it to the physician because it could indicate a clotting deficiency
- D. Send a urine specimen to the lab
Correct Answer: A
Rationale: Phenytoin commonly causes reddish-brown urine, a benign side effect, so informing the client is appropriate. Testing or reporting is unnecessary unless other symptoms suggest a problem.
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The client with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? Select all that apply.
- A. Ensure that all room walls are painted with colors that blend.
- B. Use a white board and a black marker when writing out lists.
- C. Place Velcro tabs on wall light switches to ease locating them.
- D. Ensure that doorknobs on the doors are a bright contrasting color.
- E. Match the color of dishes with the color of table-cloths or placemats.
Correct Answer: B,C,D
Rationale: Using black on white enhances readability. Velcro tabs on light switches aid location in low vision. Contrasting doorknob colors improve safety. Blending wall colors or matching dish and tablecloth colors worsens visual discrimination.
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.
The client's eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye and 20/30 in the left eye. How should the nurse interpret these results?
- A. The client has elevated intraocular pressure in both eyes.
- B. The client needs testing for glaucoma with a tonometer.
- C. The left eye is closer to normal vision than the right eye.
- D. The client has errors of refraction indicating astigmatism.
Correct Answer: C
Rationale: The Snellen chart is used to test distance vision. The numbers recorded indicate that at 20 feet (the first number) the client is able to read what a person with normal vision can read at another distance (second number). The left eye's vision recorded as 20/30 has better vision than the right eye with vision recorded as 20/40. The Snellen chart is not used to measure intraocular pressure, suggest glaucoma testing, or determine astigmatism.
The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?
- A. Elderly clients react to pain the same way any other age group does.
- B. The elderly client usually requires more pain medication.
- C. Reaction to painful stimuli may be decreased with age.
- D. The elderly client should use the Wong scale to assess pain.
Correct Answer: C
Rationale: Age-related sensory decline reduces pain perception in the elderly, affecting reporting. Pain reaction varies, more medication is not standard, and the Wong scale is pediatric.
The nurse is concerned that the client in a long-term care facility is experiencing retinal detachment. Which intervention should the nurse implement first?
- A. Flush the eye thoroughly with saline solution and apply a pressure bandage.
- B. Apply an eye shield to the affected eye and give a prescribed oral analgesic.
- C. Notify the HCP; prepare for transport to a facility for ophthalmological care.
- D. Patch both eyes and place the client in a prone position until blurring stops.
Correct Answer: C
Rationale: The nurse should contact the HCP and secure an ophthalmological evaluation promptly. Flushing the eye and applying a pressure bandage may cause further injury and delay treatment. Applying an eye shield and analgesic or patching both eyes delays securing treatment.