Nokea
The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching?
- A. I should use magnification devices as much as possible.
- B. I will look at my Amsler grid at least twice a week.
- C. I need to use low-watt light bulbs in my house.
- D. I am going to contact a low-vision center to evaluate my home.
Correct Answer: C
Rationale: Low-watt bulbs reduce visibility, counterproductive in macular degeneration. Magnification, Amsler grid monitoring (daily preferred), and low-vision centers are appropriate.
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The physician has ordered mannitol IV for a client with a head injury. What should the nurse closely monitor because the client is receiving mannitol?
- A. Deep tendon reflexes
- B. Urine output
- C. Level of orientation
- D. Pulse rate
Correct Answer: B
Rationale: Mannitol is a diuretic, so monitoring urine output is critical to assess its effectiveness and prevent dehydration.
Which statement indicates to the nurse the client is experiencing some hearing loss?
- A. I clean my ears every day after I take a shower.
- B. I keep turning up the sound on my television.
- C. My ears hurt, especially when I yawn.
- D. I get dizzy when I get up from the chair.
Correct Answer: B
Rationale: Turning up the television volume suggests hearing loss. Ear cleaning is unrelated, ear pain suggests infection, and dizziness indicates vestibular issues.
The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of the correct method for instilling eardrops to a child?
- A. Pull the pinna upward only to instill the eardrops.
- B. Pull the pinna to a neutral position to instill the eardrops.
- C. Pull the pinna upward and backward prior to instilling the drops.
- D. Pull the pinna downward and forward to instill the drops.
Correct Answer: D
Rationale: For children under 3, pulling the pinna down and back straightens the ear canal; for older children like a 6-year-old, down and back is still appropriate. Upward or neutral pulls are incorrect.
The client with diminished sight has problems with the glare from light. Which recommendation should the nurse make?
- A. Install fluorescent lighting throughout the home.
- B. Wear sunglasses and hats with brims when outdoors.
- C. Avoid going outdoors on days that are sunny.
- D. Use direct sunlight from windows rather than lights.
Correct Answer: B
Rationale: Wearing sunglasses and hats with brims while outdoors blocks direct light, reducing glare. Fluorescent lighting and direct sunlight increase glare, and avoiding sunny days is unnecessary.
Which intervention should the nurse include when conducting an in-service to the ancillary nursing staff on caring for elderly clients addressing normal developmental sensory changes?
- A. Ensure curtains are open when having the client read written material.
- B. Provide a variety of written material when discussing a procedure.
- C. Assist the client when getting out of the bed and sitting in the chair.
- D. Request a telephone for the hearing impaired for all elderly clients.
Correct Answer: A
Rationale: Open curtains maximize light, compensating for age-related vision decline. Varied materials, mobility assistance, and hearing-impaired phones are less universally applicable.