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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During an assessment, the nurse covers the client's right eye and then observes a shift in the client's gaze after the eye is uncovered. Which conclusion should the nurse make about the results of the test?
- A. The client has opacity of the lens.
- B. The client has absence of the blink reflex.
- C. The client has increased intraocular pressure.
- D. The client has weakness in the extraocular muscles.
Correct Answer: D
Rationale: Covering and then uncovering the client's eye and then observing for a shift in the client's gaze is the cover-uncover test used to detect weakness in the extraocular muscles. Lens opacity is detected by direct observation. Stroking the eyelashes will evoke the blink reflex. The intraocular pressure is measured by tonometry.
An adult client is admitted for removal of a cataract from her right eye. Which of the following would the client likely have experienced as a result of the cataracts?
- A. Acute eye pain
- B. Redness and constant itching of the right eye
- C. Gradual blurring of vision
- D. Severe headaches and dizziness
Correct Answer: C
Rationale: Cataracts cause gradual blurring of vision due to lens opacity, not acute pain, itching, or headaches.
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 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.
A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is to:
- A. check for bladder distention.
- B. place him in the Trendelenburg position.
- C. administer PRN pain medication.
- D. position him on his left side.
Correct Answer: A
Rationale: Symptoms suggest autonomic dysreflexia, often triggered by bladder distention, requiring immediate assessment and intervention.