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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The nurse is caring for the client who has a visual deficit. Which approach should the nurse use?
- A. Acknowledge presence by greeting the client by name.
- B. Stand directly in front of the client to speak to the client.
- C. Use a loud, clear voice to address or talk to the client.
- D. Touch to get the client's attention before providing care.
Correct Answer: A
Rationale: Informing the client of the nurse's presence by greeting them by name puts the client at ease and allows participation in care. Standing directly in front may not align with the client's field of vision, loud voices are unnecessary, and touching without explanation can startle.
The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact?
- A. The client can identify cold and hot on the face.
- B. The client does not have any tongue tremor.
- C. The client has no ptosis of the eyelids.
- D. The client is able to identify a peppermint smell.
Correct Answer: D
Rationale: Cranial nerve I (olfactory) is assessed by identifying smells like peppermint. Temperature sensation (trigeminal), tongue movement (hypoglossal), and ptosis (oculomotor) involve other nerves.
The emergency department nurse is assessing a client who has a needle in the sclera of the right eyeball just below the iris. Which should the nurse implement first?
- A. Remove the needle with tweezers.
- B. Notify an ophthalmologist to care for the client.
- C. Stabilize the right eye and place a patch over the left eye.
- D. Irrigate the right eye to wash the needle out of the eye.
Correct Answer: C
Rationale: Stabilizing the eye and patching the unaffected eye prevents movement and further damage until surgical removal. Removing the needle, notifying later, or irrigating risks harm.
The client tells the nurse, 'I have something under my upper eyelid and don't recall how it happened.' The client has no eye redness or pain and no changes in vision. Which intervention should the nurse implement?
- A. Notify the client's health care provider for guidance.
- B. Flush the client's eye with sterile saline for 10 minutes.
- C. Evert the upper lid with a cotton-tipped applicator for examination.
- D. Place an eye patch, taping from the outside of the eye to the inside.
Correct Answer: C
Rationale: Since the client has no pain or vision changes, the nurse should assess by everting the upper eyelid with a cotton-tipped applicator to visualize the issue. Contacting the HCP, flushing, or patching should follow assessment.
The client is one day post-surgical repair of a retinal detachment. Which assessment finding is most important for the nurse to report immediately to the HCP because it indicates a significant complication?
- A. Surgical eye pain rated 2 on a 10-point scale
- B. Increased tearing from the surgical eye
- C. Blurred vision and floaters in the surgical eye
- D. Dryness and injection of the sclera in the surgical eye
Correct Answer: C
Rationale: Blurred vision and floaters in the surgical eye may occur with redetachment of the retina and would warrant additional surgery. A low level of postoperative pain does not indicate a significant complication. Watery drainage is not a specific sign for concern and is less serious than changes in visual acuity. Dryness and injection of the sclera may or may not resolve without treatment, but loss of visual acuity is a more critical sign of complication.