Nokea
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 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 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.
Which assessment technique should the nurse use to assess the client's optic nerve?
- A. Have the client identify different smells.
- B. Have the client discriminate between sugar and salt.
- C. Have the client read the Snellen chart.
- D. Have the client say 'ah' to assess the rise of the uvula.
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.
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.
The nurse is assessing the older adult client with otosclerosis. Which diagnostic characteristics should the nurse associate with otosclerosis?
- A. Bone conduction is greater than air conduction.
- B. Hearing aids are not effective in restoring hearing.
- C. Surgical restoration of hearing is not possible.
- D. Serial audiograms show progressive hearing loss.
Correct Answer: A
Rationale: Otosclerosis impairs the air conduction of sound waves; therefore, bone conduction is typically greater than air conduction. Hearing aids and surgical restoration (stapedectomy) are effective, and progressive hearing loss is detected by serial audiograms.