Nokea
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.
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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 client is diagnosed with Ménière's disease. Which statement indicates the client understands the medical management for this disease?
- A. After intravenous antibiotic therapy, I will be cured.
- B. I will have to use a hearing aid for the rest of my life.
- C. I must adhere to a low-sodium diet, 2,000 mg/day.
- D. I should sleep with the head of my bed elevated.
Correct Answer: C
Rationale: A low-sodium diet (2,000 mg/day) reduces fluid retention in Ménière's disease, managing vertigo. Antibiotics are irrelevant, hearing aids are not always needed, and elevation is ineffective.
The client is one day post-surgical repair of a retinal detachment. Which assessment finding is most important for the nurse to report immediately to the HCP because it indicates a significant complication?
- A. Surgical eye pain rated 2 on a 10-point scale
- B. Increased tearing from the surgical eye
- C. Blurred vision and floaters in the surgical eye
- D. Dryness and injection of the sclera in the surgical eye
Correct Answer: C
Rationale: Blurred vision and floaters in the surgical eye may occur with redetachment of the retina and would warrant additional surgery. A low level of postoperative pain does not indicate a significant complication. Watery drainage is not a specific sign for concern and is less serious than changes in visual acuity. Dryness and injection of the sclera may or may not resolve without treatment, but loss of visual acuity is a more critical sign of complication.
Which of the following would not be included in the nursing care plan for a client with Parkinson's disease?
- A. Restricting his intake of oral fluids
- B. Range of motion exercises
- C. Allowing him to carry out activities of daily living by himself even though he is very slow
- D. Providing him with diversionary tasks that require motor coordination of hands
Correct Answer: A
Rationale: Fluids should be encouraged to prevent dehydration and manage drooling in Parkinson's disease, making restriction inappropriate.
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.