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An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
- A. Increased cerebral blood flow
- B. Respiratory depression
- C. Increased intracranial pressure
- D. Hyperoxygenation of the cerebrum
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.
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The nurse is caring for the client with macular degeneration. Which illustration should the nurse associate with the field disturbance seen by the client?
- A. Limited peripheral vision is shown in illustration 1.
- B. Distorted central vision as seen in illustration 2.
- C. Illustration 3 shows a normal visual field.
- D. Illustration 4 shows a blurred visual field.
Correct Answer: B
Rationale: Distorted central vision as seen in illustration 2 is characteristic of macular degeneration. The macula is the area of the fundus responsible for central vision. When the cells in the macula have been damaged, central vision is impaired. Illustration 1 shows glaucoma, 3 shows normal vision, and 4 shows blurred vision from various conditions.
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 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 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 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.