Nokea
An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss?
- A. Place frequently used items on the affected side
- B. Position her so that her affected side is toward the activity in the room
- C. Encourage her to turn her head from side to side to scan the environment on the affected side
- D. Stand on the affected side while assisting her in ambulating
Correct Answer: C
Rationale: Encouraging head turning to scan the environment compensates for right homonymous hemianopia by ensuring awareness of the affected side.
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Which instruction should the nurse discuss with the female client with viral conjunctivitis?
- A. Contact the HCP if pain occurs.
- B. Do not share towels or linens.
- C. Apply warm compresses to the eyes.
- D. Apply makeup very lightly.
Correct Answer: B
Rationale: Not sharing towels or linens prevents viral conjunctivitis spread. Pain warrants HCP contact but is less preventive, compresses are soothing but secondary, and makeup should be avoided.
A client complains of tinnitus and dizziness and has a diagnosis of Ménière's disease. She asks the nurse, 'What is the cause of Ménière's disease?' What is the nurse's best response?
- A. Ménière's disease is caused by a virus.'
- B. The cause of Ménière's disease is unknown.'
- C. Ménière's disease frequently follows a streptococcal infection.'
- D. It is hereditary. Both of your parents carried the gene for Ménière's disease.'
Correct Answer: B
Rationale: The exact cause of Ménière's disease is unknown, though it involves fluid imbalance in the inner ear.
The nurse is reviewing home management strategies with the client who has dry macular degeneration. The nurse should review using which objects with the client? Select all that apply.
- A. Protective goggles
- B. Lighting that is bright
- C. An Amsler grid
- D. A soft eye patch
- E. Magnification device
Correct Answer: B,C,E
Rationale: The nurse should review using bright lighting because it improves vision and promotes safety. An Amsler grid monitors for sudden onset or distortion of vision, indicating worsening macular degeneration. Magnification devices decrease eyestrain and promote safety. Protective goggles and eye patches are not specifically related to macular degeneration.
Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply.
- A. Perforation of the tympanic membrane.
- B. Chronic exposure to loud noises.
- C. Recurrent ear infections.
- D. Use of nephrotoxic medications.
- E. Multiple piercings in the auricle.
Correct Answer: A,B,C,D
Rationale: Tympanic perforation, loud noise, ear infections, and ototoxic medications (e.g., aminoglycosides) cause hearing loss. Auricle piercings are cosmetic and unrelated.
The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene?
- A. Carefully remove the stick from the eye.
- B. Stabilize the stick as best as possible.
- C. Flush the eye with water if available.
- D. Place the young man in a high-Fowler's position.
Correct Answer: B
Rationale: Stabilizing the stick prevents further damage until surgical removal. Removing it risks bleeding, flushing is contraindicated, and positioning is secondary.