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.
You may also like to solve these questions
The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first?
- A. Teach the signs of increased intraocular pressure.
- B. Position the client as prescribed by the surgeon.
- C. Assess the eye for signs/symptoms of complications.
- D. Explain the importance of follow-up visits.
Correct Answer: B
Rationale: Positioning as prescribed (e.g., face-down) is critical to maintain gas tamponade efficacy and retinal reattachment. Teaching, assessment, and follow-up are secondary.
The nurse is caring for the client with macular degeneration. Which illustration should the nurse associate with the field disturbance seen by the client?
- A. Limited peripheral vision is shown in illustration 1.
- B. Distorted central vision as seen in illustration 2.
- C. Illustration 3 shows a normal visual field.
- D. Illustration 4 shows a blurred visual field.
Correct Answer: B
Rationale: Distorted central vision as seen in illustration 2 is characteristic of macular degeneration. The macula is the area of the fundus responsible for central vision. When the cells in the macula have been damaged, central vision is impaired. Illustration 1 shows glaucoma, 3 shows normal vision, and 4 shows blurred vision from various conditions.
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 with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? Select all that apply.
- A. Ensure that all room walls are painted with colors that blend.
- B. Use a white board and a black marker when writing out lists.
- C. Place Velcro tabs on wall light switches to ease locating them.
- D. Ensure that doorknobs on the doors are a bright contrasting color.
- E. Match the color of dishes with the color of table-cloths or placemats.
Correct Answer: B,C,D
Rationale: Using black on white enhances readability. Velcro tabs on light switches aid location in low vision. Contrasting doorknob colors improve safety. Blending wall colors or matching dish and tablecloth colors worsens visual discrimination.
The nurse is providing teaching on the home treatment of acute sinusitis. Which interventions should the nurse advise the client to implement? Select all that apply.
- A. Take over-the-counter ranitidine.
- B. Apply warm compresses to the face.
- C. Use saline nasal spray as directed.
- D. Take over-the-counter pseudoephedrine.
- E. Spend time outdoors in the sunlight.
Correct Answer: B,C,D
Rationale: Applying warm compresses, using saline nasal spray, and taking a decongestant like pseudoephedrine relieve nasal and sinus congestion. Ranitidine treats dyspepsia, and sunlight exposure is unrelated to sinusitis.