Nokea
The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from a cataract. Which question will help determine whether a cataract is developing?
- A. Has your ability to perceive colors changed?
- B. Does your vision appear distorted or wavy?
- C. Does the center of your visual field appear dark?
- D. Do you see random flashes of bright light?
Correct Answer: A
Rationale: Asking about a change in the ability to perceive colors will help in determining cataract development. Cataract formation involves the lens of the eye becoming more opaque, thus decreasing the vibrancy of colors. Distorted central vision is a sign of macular degeneration. A darkened area in the center of the visual field is associated with macular degeneration. Seeing flashes of bright lights is associated with retinal detachment.
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The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching?
- A. The client must lie flat with the face down.
- B. The head of the bed must be elevated 45 degrees.
- C. The client should wear sunglasses when outside.
- D. The client should avoid reading for three (3) weeks.
Correct Answer: A
Rationale: Face-down positioning maintains gas tamponade pressure on the retina, aiding reattachment. Elevation, sunglasses, and reading restrictions are secondary or incorrect.
The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room?
- A. Determine if the client has loss of vision in the same half of each visual field.
- B. Find out if the client prefers the bed by the window or by the bathroom.
- C. Request dietary to place the meat at 12:00 on each plate and vegetables at 09:00 and 15:00.
- D. Request a physical therapy consult to assess the client's mobility issues.
Correct Answer: A
Rationale: Homonymous hemianopia (loss of half the visual field) from a CVA affects safety and orientation, requiring immediate assessment. Bed preference, dietary setup, and PT consults are secondary.
The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?
- A. Elderly clients react to pain the same way any other age group does.
- B. The elderly client usually requires more pain medication.
- C. Reaction to painful stimuli may be decreased with age.
- D. The elderly client should use the Wong scale to assess pain.
Correct Answer: C
Rationale: Age-related sensory decline reduces pain perception in the elderly, affecting reporting. Pain reaction varies, more medication is not standard, and the Wong scale is pediatric.
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.
Which assessment technique should the nurse use to assess the client's optic nerve?
- A. Have the client identify different smells.
- B. Have the client discriminate between sugar and salt.
- C. Have the client read the Snellen chart.
- D. Have the client say 'ah' to assess the rise of the uvula.
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.