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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 client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.
The client with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? Select all that apply.
- A. Ensure that all room walls are painted with colors that blend.
- B. Use a white board and a black marker when writing out lists.
- C. Place Velcro tabs on wall light switches to ease locating them.
- D. Ensure that doorknobs on the doors are a bright contrasting color.
- E. Match the color of dishes with the color of table-cloths or placemats.
Correct Answer: B,C,D
Rationale: Using black on white enhances readability. Velcro tabs on light switches aid location in low vision. Contrasting doorknob colors improve safety. Blending wall colors or matching dish and tablecloth colors worsens visual discrimination.
The client is two (2) hours postoperative right-ear mastoidectomy. Which assessment data should be reported to the health-care provider?
- A. Complaints of aural fullness.
- B. Hearing loss in the affected ear.
- C. No vertigo.
- D. Facial drooping.
Correct Answer: D
Rationale: Facial drooping suggests cranial nerve VII injury, a serious complication post-mastoidectomy, requiring immediate reporting. Fullness and hearing loss are expected, and no vertigo is normal.
The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test?
- A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis.
- B. This is of diagnostic value in only 25% of patients with myasthenia gravis.
- C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis.
- D. Tensilon works by blocking the action of acetylcholine at the myoneural junction.
Correct Answer: A
Rationale: A positive Tensilon test shows increased muscle strength within one minute, confirming myasthenia gravis, as Tensilon enhances acetylcholine activity.
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.