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The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client?
- A. Suggest using extra seasoning when cooking.
- B. Instruct the client to keep a seven (7)-day food diary.
- C. Refer the client to a dietitian immediately.
- D. Recommend eating three (3) meals a day.
Correct Answer: B
Rationale: A food diary identifies intake patterns and weight loss causes, guiding intervention. Extra seasoning is premature, dietitian referral is secondary, and three meals are standard advice.
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The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
- A. Do not push or pull objects heavier than 50 pounds.
- B. Lie on the affected eye with two pillows at night.
- C. Wear glasses or metal eye shields at all times.
- D. Bend and stoop carefully for the rest of your life.
Correct Answer: C
Rationale: Wearing eye shields protects the eye post-cataract surgery, especially at night. Heavy lifting is restricted lighter, lying on the affected eye is avoided, and lifelong bending restrictions are excessive.
Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply.
- A. Perforation of the tympanic membrane.
- B. Chronic exposure to loud noises.
- C. Recurrent ear infections.
- D. Use of nephrotoxic medications.
- E. Multiple piercings in the auricle.
Correct Answer: A,B,C,D
Rationale: Tympanic perforation, loud noise, ear infections, and ototoxic medications (e.g., aminoglycosides) cause hearing loss. Auricle piercings are cosmetic and unrelated.
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.
Which of the following would not be included in the nursing care plan for a client with Parkinson's disease?
- A. Restricting his intake of oral fluids
- B. Range of motion exercises
- C. Allowing him to carry out activities of daily living by himself even though he is very slow
- D. Providing him with diversionary tasks that require motor coordination of hands
Correct Answer: A
Rationale: Fluids should be encouraged to prevent dehydration and manage drooling in Parkinson's disease, making restriction inappropriate.
The nurse is reviewing home management strategies with the client who has dry macular degeneration. The nurse should review using which objects with the client? Select all that apply.
- A. Protective goggles
- B. Lighting that is bright
- C. An Amsler grid
- D. A soft eye patch
- E. Magnification device
Correct Answer: B,C,E
Rationale: The nurse should review using bright lighting because it improves vision and promotes safety. An Amsler grid monitors for sudden onset or distortion of vision, indicating worsening macular degeneration. Magnification devices decrease eyestrain and promote safety. Protective goggles and eye patches are not specifically related to macular degeneration.