Nokea
The nurse is admitting a patient for surgery who has functional blindness for several years and is cared for by the patient's spouse. Which of the following actions is most important to implement during the initial assessment?
- A. Obtain more information about the cause of the patient's vision loss.
- B. Obtain information from the spouse about the patient's special needs.
- C. Make eye contact with the patient and ask about any need for assistance.
- D. Perform an evaluation of the patient's visual acuity using a Snellen chart.
Correct Answer: C
Rationale: Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment.
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The nurse is caring for a patient with age-related macular degeneration who has just had photodynamic therapy. Which of the following statements by the patient indicates that the discharge teaching has been effective?
- A. I will need to use bright lights to read for at least the next week.
- B. I will use drops to keep my pupils dilated until my appointment.
- C. I will not use facial lotions near my eyes during the recovery period.
- D. I will keep covered with long-sleeve shirts and pants for the next 5 days.
Correct Answer: D
Rationale: The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on use of facial lotions, medications to keep the pupils dilated are not appropriate, and bright lights would increase the risk for damage caused by the treatment.
The nurse is caring for a patient with persistent otitis media. Which of the following findings should the nurse expect to assess?
- A. Ear pain
- B. Fever
- C. Hearing loss
- D. Tinnitus
- E. Fluid drainage from the ear
Correct Answer: A,C,E
Rationale: Persistent otitis media is characterized by ear pain, hearing loss, and potential fluid drainage from the ear. Fever may occur but is less consistent, and tinnitus is not a primary symptom unless associated with complications.
A patient with hearing loss asks the nurse about the use of a cochlear implant. Which of the following information will the nurse include when replying to the patient?
- A. Cochlear implants require training in order to receive the full benefit.
- B. Cochlear implants are not useful for patients with congenital deafness.
- C. Cochlear implants are most helpful as an early intervention for presbycusis.
- D. Cochlear implants improve hearing in patients with conductive hearing loss.
Correct Answer: A
Rationale: Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.
The nurse is caring for a patient with an acute attack of Méni?¨re's disease. Which of the following actions carried out by a family member that is visiting the patient should the nurse intervene?
- A. Raises the side rails on the bed
- B. Turns on the patient's television
- C. Turns the patient to the right side
- D. Places an emesis basin at the bedside
Correct Answer: B
Rationale: Watching television may exacerbate the symptoms of an acute attack of Méni?¨re's disease. The other actions are appropriate.
The nurse is caring for a patient in the eye clinic who has 20/200 vision with the use of corrective lenses. Which of the following information should the nurse include when providing patient teaching?
- A. How to use a cane safely
- B. How to access audio books
- C. Where Braille instruction is available
- D. Where to obtain specialized magnifiers
Correct Answer: D
Rationale: Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.