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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.
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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 reviewing the new nurse's discharge instructions for the client following outpatient cataract surgery. Which statement should the nurse remove from the discharge instructions?
- A. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
- B. Clean the eye with a clean tissue; wipe from inner to outer eye.
- C. Cough and deep breathe every 2 to 3 hours while you are awake.
- D. Avoid lying on the side of the affected eye the night after surgery.
Correct Answer: C
Rationale: The client should not cough because this will increase the pressure within the eye and risk for complications. Lifting heavy objects increases pressure on the surgical eye. The surgical eye should be cleaned with a clean tissue from the inner to outer canthus to prevent obstruction of the ducts with drainage. Lying on the side of the surgical eye can increase pressure on the surgical eye.
The client is two (2) hours postoperative right-ear mastoidectomy. Which assessment data should be reported to the health-care provider?
- A. Complaints of aural fullness.
- B. Hearing loss in the affected ear.
- C. No vertigo.
- D. Facial drooping.
Correct Answer: D
Rationale: Facial drooping suggests cranial nerve VII injury, a serious complication post-mastoidectomy, requiring immediate reporting. Fullness and hearing loss are expected, and no vertigo is normal.
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 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.