Nokea
The nurse completed teaching the client with a corneal abrasion about proper care of the injury. Which statements indicate that the client understood the teaching? Select all that apply.
- A. I should promptly report a sudden absence of pain.
- B. I should keep my affected eye uncovered when up.
- C. I should insert the eye drops 10 to 15 seconds apart.
- D. I should leave the eye patch in place for 24 hours.
- E. I will avoid rubbing my affected eye or the eye patch.
Correct Answer: D,E
Rationale: Patching the eye for 24 hours reduces irritation and promotes healing. Avoiding rubbing prevents reinjury. Sudden absence of pain, keeping the eye uncovered, and short intervals between drops are incorrect.
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Which assessment technique should the nurse use to assess the client's optic nerve?
- A. Have the client identify different smells.
- B. Have the client discriminate between sugar and salt.
- C. Have the client read the Snellen chart.
- D. Have the client say 'ah' to assess the rise of the uvula.
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.
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.
How should a nurse walk a client who is blind?
- A. Stand slightly behind the client and tell her when to turn
- B. Stand slightly behind and to the side of the client and guide her by holding her hand
- C. Walk slightly ahead with the client's arm inside the nurse's arm
- D. Walk beside the client and gently guide her by grasping her elbow
Correct Answer: C
Rationale: Walking slightly ahead with the client's arm inside the nurse's arm provides guidance and safety for a blind client.
The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following?
- A. Aspiration pneumonia
- B. Decubitus ulcers
- C. Bladder distention
- D. Hypertensive crisis
Correct Answer: A
Rationale: Difficulty swallowing increases the risk of aspiration pneumonia, making it the priority in Guillain-Barré syndrome.
The nurse is assessing the client receiving brimonidine eye drops. Which assessment findings will the nurse recognize as known side effects of brimonidine? Select all that apply.
- A. Blurred vision
- B. Ocular itching
- C. Ocular stinging
- D. Hearing loss
- E. Conjunctivitis
Correct Answer: A,B,C,E
Rationale: Brimonidine (Alphagan) is an alpha-2 adrenergic agonist; the nurse should recognize blurred vision, ocular itching, ocular stinging, and conjunctivitis as side effects of brimonidine. Hearing loss is not a side effect of brimonidine.