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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 recovering at home following a stapedectomy for otosclerosis reports having dizziness. To decrease symptoms, which interventions should the nurse recommend? Select all that apply.
- A. Refrain from sudden movements.
- B. Avoid chewing on the affected side.
- C. Avoid lifting objects that are heavy.
- D. Minimize bending over at the waist.
- E. Restrict the intake of oral fluids.
Correct Answer: A,C,D
Rationale: Refraining from sudden movements, avoiding heavy lifting, and minimizing bending decrease dizziness by reducing fluid shifts in the inner ear. Chewing and fluid restriction do not affect dizziness.
The nurse is caring for the client who has a visual deficit. Which approach should the nurse use?
- A. Acknowledge presence by greeting the client by name.
- B. Stand directly in front of the client to speak to the client.
- C. Use a loud, clear voice to address or talk to the client.
- D. Touch to get the client's attention before providing care.
Correct Answer: A
Rationale: Informing the client of the nurse's presence by greeting them by name puts the client at ease and allows participation in care. Standing directly in front may not align with the client's field of vision, loud voices are unnecessary, and touching without explanation can startle.
The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply.
- A. Do not touch the tip of the medication container to the eye.
- B. Apply gentle pressure on the outer canthus of the eye.
- C. Apply sterile gloves prior to instilling eyedrops.
- D. Hold the lower lid down and instill drops into the conjunctiva.
- E. Gently pat the skin to absorb excess eyedrops on the cheek.
Correct Answer: A,D,E
Rationale: Avoiding container contact prevents contamination, instilling into the conjunctiva ensures absorption, and patting excess drops maintains hygiene. Pressure on the outer canthus is incorrect (nasolacrimal duct pressure prevents systemic absorption), and sterile gloves are unnecessary.
The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include?
- A. Limit oral fluid intake to 1000 mL daily.
- B. Eat foods that are high in omega-3 fatty acids.
- C. Have annual eye exams with an eye specialist.
- D. Use timolol maleate eye drops when feeling eye pressure.
Correct Answer: C
Rationale: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction and omega-3 fatty acids do not affect intraocular pressure. Elevated intraocular pressure cannot be felt, and timolol maleate should be used as prescribed.
An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss?
- A. Place frequently used items on the affected side
- B. Position her so that her affected side is toward the activity in the room
- C. Encourage her to turn her head from side to side to scan the environment on the affected side
- D. Stand on the affected side while assisting her in ambulating
Correct Answer: C
Rationale: Encouraging head turning to scan the environment compensates for right homonymous hemianopia by ensuring awareness of the affected side.