Nokea
The nurse is assessing a client and performs a whisper test. Which should the nurse implement? Rank in order of performance.
- A. Have the client cover the ear not being tested.
- B. Stand 12 to 24 inches to the side of the client.
- C. Explain to the client to repeat what the nurse says.
- D. Repeat the test for the opposite ear.
- E. Ask the client if he/she is willing to participate in the test.
Correct Answer: E,C,B,A,D
Rationale: 1) Ask for participation (consent); 2) Explain the procedure; 3) Position 12–24 inches away; 4) Cover the non-tested ear; 5) Repeat for the opposite ear.
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The client with macular degeneration is told the condition is progressing to an advanced stage. Which findings should the nurse expect when completing the assessment? Select all that apply.
- A. Curtain appearance over part of the visual field
- B. Loss of peripheral vision in the affected eye
- C. Difficulty seeing in dimly lit environments
- D. Visual distortions in the central vision
- E. Clouding of the lens in both eyes
Correct Answer: C,D
Rationale: Difficulty seeing in dimly lit environments is from the slow breakdown of the outer layer of the retina and the formation of drusen within the macula. The macula is the area of central vision, and with macular degeneration, there is the loss or distortion of central vision. Curtain appearance is associated with retinal detachment, peripheral vision loss with glaucoma, and clouding of the lens with cataracts.
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician's orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, 'I can't believe I really had a seizure. My mom says she was in the room when it happened, but I don't even remember it.' What is the best interpretation of his comments?
- A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
- B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
- C. Inability to remember the seizure is a normal response of a person who has had a seizure.
- D. They are an indication that he would rather not talk about his seizure at this time.
Correct Answer: C
Rationale: Amnesia for the seizure event is a normal response due to altered consciousness during a generalized seizure.
The nurse completes an assessment of the older adult client. Which disorder should the nurse associate with the finding illustrated?
- A. Glaucoma
- B. Arcus senilis
- C. Cataract
- D. Mydriasis
Correct Answer: C
Rationale: The illustration shows opacity of the lens of the eye. The nurse should associate this finding with a cataract. Glaucoma causes increased pressure within the eye and is not visible. Arcus senilis is a bluish-white ring within the outer edge of the cornea, which is not present in this illustration. Mydriasis is constriction of the pupil, which is not present in the illustration.
The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply.
- A. Do not touch the tip of the medication container to the eye.
- B. Apply gentle pressure on the outer canthus of the eye.
- C. Apply sterile gloves prior to instilling eyedrops.
- D. Hold the lower lid down and instill drops into the conjunctiva.
- E. Gently pat the skin to absorb excess eyedrops on the cheek.
Correct Answer: A,D,E
Rationale: Avoiding container contact prevents contamination, instilling into the conjunctiva ensures absorption, and patting excess drops maintains hygiene. Pressure on the outer canthus is incorrect (nasolacrimal duct pressure prevents systemic absorption), and sterile gloves are unnecessary.
The nurse is caring for the client who has a visual deficit. Which approach should the nurse use?
- A. Acknowledge presence by greeting the client by name.
- B. Stand directly in front of the client to speak to the client.
- C. Use a loud, clear voice to address or talk to the client.
- D. Touch to get the client's attention before providing care.
Correct Answer: A
Rationale: Informing the client of the nurse's presence by greeting them by name puts the client at ease and allows participation in care. Standing directly in front may not align with the client's field of vision, loud voices are unnecessary, and touching without explanation can startle.