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How should a nurse walk a client who is blind?
- A. Stand slightly behind the client and tell her when to turn
- B. Stand slightly behind and to the side of the client and guide her by holding her hand
- C. Walk slightly ahead with the client's arm inside the nurse's arm
- D. Walk beside the client and gently guide her by grasping her elbow
Correct Answer: C
Rationale: Walking slightly ahead with the client's arm inside the nurse's arm provides guidance and safety for a blind client.
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The nurse is teaching the client who has otitis media. To reduce the risk of recurrent otitis media, which vaccine should the nurse recommend?
- A. Varicella vaccine
- B. Pneumococcal vaccine
- C. Typhoid vaccine
- D. Zoster vaccine
Correct Answer: B
Rationale: Pneumococcal vaccine can reduce the risk of ear infections. Varicella, typhoid, and zoster vaccines prevent other conditions.
The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Check the client’s hemoglobin A1c.
- C. Assess the client’s vision using the Amsler grid.
- D. Teach the client about controlling blood glucose levels.
- E. Determine where the spots appear to be in the client’s field of vision.
Correct Answer: A,E,C,B,D
Rationale: 1) Notify HCP (urgent for possible diabetic retinopathy); 2) Determine spot location (assess severity); 3) Amsler grid (evaluate central vision); 4) Check HbA1c (assess control); 5) Teach glucose control (long-term management).
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 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 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.