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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.
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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.
Which of the following interventions should the nurse implement for a patient who has just been diagnosed with viral conjunctivitis?
- A. Explain the purpose of antiviral eye drops.
- B. Show how to perform eye irrigation safely.
- C. Instruct about how to insert soft contact lenses.
- D. Demonstrate appropriate handwashing technique.
Correct Answer: D
Rationale: Good hand hygiene is the major means to prevent the spread of conjunctivitis. Antiviral drops and eye irrigation will not be helpful in shortening the disease process. Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva.
The camp nurse is caring for a patient who is complaining of bilateral eye pain after a campfire log exploded, sending sparks into the patient's eyes. Which of the following actions should the nurse take first?
- A. Apply ice packs to the eyes.
- B. Flush the eyes with sterile saline.
- C. Cover the eyes with dry sterile patches and protective eye shields.
- D. Apply antiseptic ophthalmic ointment from the first-aid kit to the eyes.
Correct Answer: C
Rationale: Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. Except in the case of chemical exposure, the nurse should not begin treatment until the patient has been assessed by a health care provider and orders are available.
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.
Which of the following nursing diagnoses is priority when caring for a patient who is experiencing an acute attack of Méni?¨re's disease?
- A. Risk for falls as evidenced by impaired balance
- B. Impaired verbal communication related to vulnerability (tinnitus)
- C. Bathing self-care deficit related to weakness (vertigo)
- D. Imbalanced nutrition: less than body requirements related to insufficient dietary intake (nausea)
Correct Answer: A
Rationale: All the nursing diagnoses are appropriate, but because sudden acute attacks of vertigo, the major focus of nursing care is to prevent injuries associated with impaired balance.