Nokea
The nurse is admitting a patient to the outpatient surgery unit who is scheduled for cataract extraction and implantation of an intraocular lens. Which of the following information has the most immediate implications for the patient's care?
- A. The patient has not eaten anything for 8 hours.
- B. The patient takes three antihypertensive medications.
- C. The patient gets nauseated with general anaesthesia.
- D. The patient has had blurred vision for several years.
Correct Answer: B
Rationale: Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic to minimize systemic effects and monitoring of blood pressure are indicated for this patient. Patients are expected to be NPO for 6-8 hours before the surgical procedure. Blurred vision is an expected finding with cataracts. Cataract extraction and intraocular lens implantation are done using local anaesthesia.
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The nurse is caring for a patient with neural presbycusis. Which of the following hearing changes should the nurse expect with this type of presbycusis?
- A. Loss of high-pitched sounds
- B. Loss of speech discrimination
- C. Uniform loss for all frequencies
- D. Range of hearing loss with low frequencies
Correct Answer: B
Rationale: The hearing change with a neural presbycusis is a loss of speech discrimination. Loss of high-pitched sounds accompanies a sensory presbycusis. A metabolic presbycusis has a hearing change that is uniform for all frequencies, accompanied by recruitment. A cochlear presbycusis has a hearing change that is a range of hearing loss that increases from low to high frequencies.
Which of the following assessment findings in a patient who was struck in the right eye with a baseball is a priority for the nurse to communicate to the health care provider in the emergency department?
- A. The patient complains of a right-sided headache.
- B. The sclerae on the right eye have broken blood vessels.
- C. The area around the right eye is bruised and tender to the touch.
- D. The patient complains of 'a curtain' blocking part of the visual field.
Correct Answer: D
Rationale: The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye with a ball.
The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which of the following assessment data obtained by the nurse is of most concern?
- A. The patient has a temperature of 38.1°C (100.6°F).
- B. The patient reports mild ear pain.
- C. The patient has slight redness in the ear canal.
- D. The patient reports decreased hearing in the right ear.
Correct Answer: A
Rationale: A temperature of 38.1°C (100.6°F) after treatment for acute otitis media may indicate a persistent or worsening infection, requiring immediate attention. Mild ear pain, slight redness, and decreased hearing may be residual symptoms but are less concerning unless persistent or severe.
The nurse is admitting a patient with a head injury after a motor vehicle accident who has shortness of breath and severe eye pain. Which of the following actions should the nurse take first?
- A. Elevate the head to 45 degrees.
- B. Administer the ordered analgesic.
- C. Check the patient's oxygen saturation.
- D. Examine the eye for evidence of trauma.
Correct Answer: C
Rationale: The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions also are appropriate but are not the first action the nurse will take.
The nurse is caring for a patient with a left retinal detachment who had a pneumatic retinopexy procedure. Which of the following information should be included in the discharge teaching plan?
- A. The use of bilateral eye patches to reduce movement of the operative eye
- B. The need to wear dark or tinted glasses
- C. The procedure for sterile dressing changes
- D. The purpose of maintaining the head in a prescribed position for several weeks
Correct Answer: D
Rationale: Following pneumatic retinopexy, maintaining the head in a prescribed position is critical to keep the gas bubble in contact with the retinal tear, promoting reattachment. Bilateral eye patches are not typically used, dark glasses may be recommended for comfort but are not the focus, and sterile dressing changes are not standard for this procedure.