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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.
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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.
The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room?
- A. Determine if the client has loss of vision in the same half of each visual field.
- B. Find out if the client prefers the bed by the window or by the bathroom.
- C. Request dietary to place the meat at 12:00 on each plate and vegetables at 09:00 and 15:00.
- D. Request a physical therapy consult to assess the client's mobility issues.
Correct Answer: A
Rationale: Homonymous hemianopia (loss of half the visual field) from a CVA affects safety and orientation, requiring immediate assessment. Bed preference, dietary setup, and PT consults are secondary.
The nurse is caring for a client diagnosed with acute otitis media. Which signs/symptoms support this medical diagnosis?
- A. Unilateral pain in the ear.
- B. Green, foul-smelling drainage.
- C. Sensation of congestion in the ear.
- D. Reports of hearing loss.
Correct Answer: A
Rationale: Unilateral ear pain is a primary symptom of acute otitis media. Foul drainage suggests chronic infection, congestion is non-specific, and hearing loss is less common acutely.
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 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.