Nokea
The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of the correct method for instilling eardrops to a child?
- A. Pull the pinna upward only to instill the eardrops.
- B. Pull the pinna to a neutral position to instill the eardrops.
- C. Pull the pinna upward and backward prior to instilling the drops.
- D. Pull the pinna downward and forward to instill the drops.
Correct Answer: D
Rationale: For children under 3, pulling the pinna down and back straightens the ear canal; for older children like a 6-year-old, down and back is still appropriate. Upward or neutral pulls are incorrect.
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The client tells the nurse about being diagnosed with 'wet type' macular degeneration. Which finding should the nurse expect to observe when examining the client's eyes using an ophthalmoscope?
- A. Growth of abnormal blood vessels in the macula has occurred.
- B. Structures in the macula have atrophied.
- C. The lens of the eye has become cloudy.
- D. The edge of the cornea has a thin grayish arc.
Correct Answer: A
Rationale: The 'wet type' of macular degeneration results from the growth of abnormal blood vessels in the macula. The blood vessels often leak fluid and blood. Atrophy occurs in dry macular degeneration, cloudy lens indicates cataract, and corneal arcus is a normal finding in older clients.
The nurse is administering eye drops to a client. Which action is correct?
- A. Ask the client to report any blurring of vision and difficulty focusing that occurs after the administration of eye drops.
- B. Apply gentle pressure to the nasolacrimal canal for one to two minutes after instillation to prevent systemic absorption.
- C. Have the client lie down with eyes closed for 45 minutes after giving drops.
- D. Gently pull the lower lid down and place medicine in the center of the eye.
Correct Answer: B
Rationale: Applying pressure to the nasolacrimal canal prevents systemic absorption of eye drops, enhancing safety and efficacy.
The nurse speaks with the client who recently learned that cataracts are developing in both of the client's eyes. Which statement made by the client should the nurse correct?
- A. It is important that I schedule my surgery as soon as possible.
- B. Usually surgery is performed on each eye at different times.
- C. My own lens will be removed when I have cataract surgery.
- D. An intraocular lens may be inserted with the surgical procedure.
Correct Answer: A
Rationale: Although there is reduced vision with beginning cataract development, a person can wait until vision worsens before having surgery. When vision is reduced to the extent that ADLs are affected, surgery should be performed as soon as possible. If both eyes have cataracts, usually the eyes are treated in separate procedures. Surgery for a cataract involves removal of the client's lens, and in most situations, the lens is replaced with an intraocular lens.
The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge teaching should the nurse discuss with the client?
- A. Instruct the client to blow the nose with the mouth closed.
- B. Explain the client will never be able to hear from the ear.
- C. Instill ophthalmic drops in both ears and then insert a cotton ball.
- D. Do not allow water to enter the ear for six (6) weeks.
Correct Answer: D
Rationale: Keeping the ear dry for six weeks prevents infection post-mastoidectomy. Blowing the nose closed increases pressure, hearing loss is not guaranteed, and ophthalmic drops are incorrect.
The client following removal of a right-sided acoustic neuroma by a translabyrinthine approach calls the nurse to report pain. The nurse finds that the client has new-onset right-sided facial drooping and numbness. Place the nurse's actions in priority order.
- A. Close the client's right eye and place a patch over it.
- B. Assess the operative incision site and assess the arms for drift.
- C. Contact the stroke team and the HCP.
- D. Medicate the client for pain unless contraindicated.
Correct Answer: B,C,D,A
Rationale: Assess the incision and arms for drift first (B), then contact the stroke team and HCP for possible complications (C), medicate for pain (D), and finally patch the eye due to inability to close it (A).