Nokea
The client has had an enucleation of the left eye. Which intervention should the nurse implement?
- A. Discuss the need for special eyeglasses.
- B. Refer the client for an ocular prosthesis.
- C. Help the client obtain a seeing-eye dog.
- D. Teach the client how to instill eyedrops.
Correct Answer: B
Rationale: An ocular prosthesis restores appearance post-enucleation, addressing psychosocial needs. Eyeglasses, guide dogs, and eyedrops are irrelevant post-enucleation.
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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 male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Check the client’s hemoglobin A1c.
- C. Assess the client’s vision using the Amsler grid.
- D. Teach the client about controlling blood glucose levels.
- E. Determine where the spots appear to be in the client’s field of vision.
Correct Answer: A,E,C,B,D
Rationale: 1) Notify HCP (urgent for possible diabetic retinopathy); 2) Determine spot location (assess severity); 3) Amsler grid (evaluate central vision); 4) Check HbA1c (assess control); 5) Teach glucose control (long-term management).
The employee health nurse is teaching a class on 'Preventing Eye Injury.' Which information should be discussed in the class?
- A. Read instructions thoroughly before using tools and working with chemicals.
- B. Wear some type of glasses when working around flying fragments.
- C. Always wear a protective helmet with eye shield around dust particles.
- D. Pay close attention to the surroundings so eye injuries will be prevented.
Correct Answer: A
Rationale: Reading instructions ensures safe tool and chemical use, preventing eye injuries. Glasses are specific, helmets are not always required, and attention is vague.
The nurse is teaching the client who has otitis media. To reduce the risk of recurrent otitis media, which vaccine should the nurse recommend?
- A. Varicella vaccine
- B. Pneumococcal vaccine
- C. Typhoid vaccine
- D. Zoster vaccine
Correct Answer: B
Rationale: Pneumococcal vaccine can reduce the risk of ear infections. Varicella, typhoid, and zoster vaccines prevent other conditions.
The nurse is assessing the older adult client with otosclerosis. Which diagnostic characteristics should the nurse associate with otosclerosis?
- A. Bone conduction is greater than air conduction.
- B. Hearing aids are not effective in restoring hearing.
- C. Surgical restoration of hearing is not possible.
- D. Serial audiograms show progressive hearing loss.
Correct Answer: A
Rationale: Otosclerosis impairs the air conduction of sound waves; therefore, bone conduction is typically greater than air conduction. Hearing aids and surgical restoration (stapedectomy) are effective, and progressive hearing loss is detected by serial audiograms.