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The elderly male client tells the nurse, 'My wife says her cooking hasn't changed, but it is bland and tasteless.' Which response by the nurse is most appropriate?
- A. Would you like me to talk to your wife about her cooking?
- B. Taste buds change with age, which may be why the food seems bland.
- C. This happens because the medications sometimes cause a change in taste.
- D. Why don't you barbecue food on a grill if you don't like your wife's cooking?
Correct Answer: B
Rationale: Age-related taste bud decline reduces taste perception, a common issue in the elderly. Talking to the wife, blaming medications, or suggesting grilling are less appropriate.
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The nurse telephones the client 1 day post-cataract surgery. Which client statement necessitates an evaluation by an ophthalmologist?
- A. My eye starts hurting about 4 hours after a pain pill.
- B. The redness in my eye is a little less than yesterday.
- C. There has never been any swelling around my eye.
- D. I can't see as well as I could yesterday after surgery.
Correct Answer: D
Rationale: A significant reduction in vision may indicate a complication such as infection or retinal detachment. Pain relieved by prescribed pain medication is within normal assessment parameters. Decreasing redness is within normal assessment parameters. No swelling is within normal assessment parameters.
The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching?
- A. I should use magnification devices as much as possible.
- B. I will look at my Amsler grid at least twice a week.
- C. I need to use low-watt light bulbs in my house.
- D. I am going to contact a low-vision center to evaluate my home.
Correct Answer: C
Rationale: Low-watt bulbs reduce visibility, counterproductive in macular degeneration. Magnification, Amsler grid monitoring (daily preferred), and low-vision centers are appropriate.
Which teaching instruction should the nurse discuss with students who are on the high school swim team when discussing how to prevent external otitis?
- A. Do not wear tight-fitting swim caps.
- B. Avoid using silicone ear plugs while swimming.
- C. Use a drying agent in the ear after swimming.
- D. Insert a bulb syringe into each ear to remove excess water.
Correct Answer: C
Rationale: A drying agent (e.g., alcohol-based drops) prevents external otitis by removing moisture. Swim caps and ear plugs are protective, and bulb syringes risk trauma.
The nurse is questioning the client about vision changes. Which symptom indicates that the client may be developing a cataract?
- A. Blurred vision, worsening at night
- B. Shooting pain in the back of one eye
- C. Increased frequency of headaches
- D. Seeing spots in the vision field of one eye
Correct Answer: A
Rationale: The lens opacity from a developing cataract diminishes vision. Blurriness and decreased night vision are early symptoms. Shooting eye pain is often associated with a subarachnoid hemorrhage, not a cataract. Headaches are not associated with cataract formation. Floating dark spots in the vision field are associated with bleeding within the eye that occurs with detached retina.
The client recently diagnosed with glaucoma tells the nurse, 'I'm having difficulty remembering to insert my eye drops. I don't have any pain or vision changes when I forget them.' Which statement is the best response?
- A. You should be diligent in inserting the eye drops; if not, then you will need surgery.
- B. You wouldn't have pain, but untreated glaucoma will eventually lead to vision loss.
- C. Tell me about your day; planning a time with a daily activity often helps as a reminder.
- D. I know this must be hard for you; not everyone is able to remember everything.
Correct Answer: C
Rationale: This is a broad opening statement and can assist the client to problem-solve an activity that could serve as a reminder to take the eye drops. The other statements are either belittling, partially incorrect, or do not help with adherence.