Nokea
The nurse is concerned that the client in a long-term care facility is experiencing retinal detachment. Which intervention should the nurse implement first?
- A. Flush the eye thoroughly with saline solution and apply a pressure bandage.
- B. Apply an eye shield to the affected eye and give a prescribed oral analgesic.
- C. Notify the HCP; prepare for transport to a facility for ophthalmological care.
- D. Patch both eyes and place the client in a prone position until blurring stops.
Correct Answer: C
Rationale: The nurse should contact the HCP and secure an ophthalmological evaluation promptly. Flushing the eye and applying a pressure bandage may cause further injury and delay treatment. Applying an eye shield and analgesic or patching both eyes delays securing treatment.
You may also like to solve these questions
The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?
- A. The client is unable to identify which way the toe is being moved.
- B. The client cannot discriminate between sharp and dull objects.
- C. The toes contract and draw together when the sole of the foot is stroked.
- D. The client is unable to identify a key in the hand with both eyes closed.
Correct Answer: D
Rationale: Abnormal stereognosis is the inability to identify objects (e.g., a key) by touch with eyes closed, indicating parietal lobe dysfunction. Toe movement, sharp/dull, and Babinski reflex test other functions.
The nurse is reviewing the new nurse's discharge instructions for the client following outpatient cataract surgery. Which statement should the nurse remove from the discharge instructions?
- A. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
- B. Clean the eye with a clean tissue; wipe from inner to outer eye.
- C. Cough and deep breathe every 2 to 3 hours while you are awake.
- D. Avoid lying on the side of the affected eye the night after surgery.
Correct Answer: C
Rationale: The client should not cough because this will increase the pressure within the eye and risk for complications. Lifting heavy objects increases pressure on the surgical eye. The surgical eye should be cleaned with a clean tissue from the inner to outer canthus to prevent obstruction of the ducts with drainage. Lying on the side of the surgical eye can increase pressure on the surgical eye.
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.
The client has a hearing loss from a possible acoustic neuroma. The nurse should prepare the client for which diagnostic test to confirm the presence of a tumor?
- A. Tympanometry
- B. Arteriogram of the cranial vessels
- C. Magnetic resonance imaging (MRI)
- D. Auditory canal biopsy
Correct Answer: C
Rationale: MRI with gadolinium enhancement is the most reliable test in determining size and anatomical location of an acoustic neuroma. Tympanometry, arteriogram, and biopsy are not used for this diagnosis.
A young man was swimming at the beach when an exceptionally large wave caused him to be drawn under the water. His family members found him in the water and pulled him ashore. He states that he heard something snap in his neck. When a nurse arrives, he is conscious and lying on his back. He states that he has no pain. He is unable to move his legs. How should he be transported?
- A. Position him in a prone position and place on a backboard.
- B. Apply a neck collar and position supine on a backboard.
- C. Log roll him to a rigid backboard.
- D. Position in an upright position with a firm neck collar.
Correct Answer: B
Rationale: A suspected neck injury requires immobilization with a neck collar and supine positioning on a backboard to prevent further spinal cord damage.