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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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Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?
- A. Suggest installing multiple smoke alarms in the home.
- B. Recommend using a night-light in the hallway and bathroom.
- C. Discuss keeping a high-humidity atmosphere in the bedroom.
- D. Encourage the client to smell food prior to eating it.
Correct Answer: A
Rationale: Olfactory decline reduces smoke detection, making multiple smoke alarms critical for safety. Night-lights address vision, humidity is unrelated, and smelling food is unreliable.
The nurse completed teaching the client with a corneal abrasion about proper care of the injury. Which statements indicate that the client understood the teaching? Select all that apply.
- A. I should promptly report a sudden absence of pain.
- B. I should keep my affected eye uncovered when up.
- C. I should insert the eye drops 10 to 15 seconds apart.
- D. I should leave the eye patch in place for 24 hours.
- E. I will avoid rubbing my affected eye or the eye patch.
Correct Answer: D,E
Rationale: Patching the eye for 24 hours reduces irritation and promotes healing. Avoiding rubbing prevents reinjury. Sudden absence of pain, keeping the eye uncovered, and short intervals between drops are incorrect.
The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?
- A. The client is unable to identify which way the toe is being moved.
- B. The client cannot discriminate between sharp and dull objects.
- C. The toes contract and draw together when the sole of the foot is stroked.
- D. The client is unable to identify a key in the hand with both eyes closed.
Correct Answer: D
Rationale: Abnormal stereognosis is the inability to identify objects (e.g., a key) by touch with eyes closed, indicating parietal lobe dysfunction. Toe movement, sharp/dull, and Babinski reflex test other functions.
The employee health nurse is teaching a class on 'Preventing Eye Injury.' Which information should be discussed in the class?
- A. Read instructions thoroughly before using tools and working with chemicals.
- B. Wear some type of glasses when working around flying fragments.
- C. Always wear a protective helmet with eye shield around dust particles.
- D. Pay close attention to the surroundings so eye injuries will be prevented.
Correct Answer: A
Rationale: Reading instructions ensures safe tool and chemical use, preventing eye injuries. Glasses are specific, helmets are not always required, and attention is vague.
The nurse is reviewing the new nurse's discharge instructions for the client following outpatient cataract surgery. Which statement should the nurse remove from the discharge instructions?
- A. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
- B. Clean the eye with a clean tissue; wipe from inner to outer eye.
- C. Cough and deep breathe every 2 to 3 hours while you are awake.
- D. Avoid lying on the side of the affected eye the night after surgery.
Correct Answer: C
Rationale: The client should not cough because this will increase the pressure within the eye and risk for complications. Lifting heavy objects increases pressure on the surgical eye. The surgical eye should be cleaned with a clean tissue from the inner to outer canthus to prevent obstruction of the ducts with drainage. Lying on the side of the surgical eye can increase pressure on the surgical eye.