Nokea
The nurse is reviewing a patient's medical record and notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. Which of the following parameters should the nurse assess?
- A. Visual acuity
- B. Pupil reaction
- C. Colour perception
- D. Peripheral vision
Correct Answer: D
Rationale: The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Colour perception and pupil reaction to light are not affected by glaucoma.
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The nurse is caring for a patient with persistent otitis media. Which of the following findings should the nurse expect to assess?
- A. Ear pain
- B. Fever
- C. Hearing loss
- D. Tinnitus
- E. Fluid drainage from the ear
Correct Answer: A,C,E
Rationale: Persistent otitis media is characterized by ear pain, hearing loss, and potential fluid drainage from the ear. Fever may occur but is less consistent, and tinnitus is not a primary symptom unless associated with complications.
Which of the following actions should the nurse take when assisting a totally blind patient to walk to the bathroom?
- A. Take the patient by the arm and lead the patient slowly to the bathroom.
- B. Have the patient place a hand on the nurse's shoulder and guide the patient.
- C. Stay beside the patient and describe any obstacles on the path to the bathroom.
- D. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.
Correct Answer: D
Rationale: When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.
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 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.
The nurse is assessing a patient in the outpatient eye clinic who has myopia and presbyopia. Which of the following assessments should the nurse implement to evaluate the effectiveness of the prescribed bifocals?
- A. Strength of the eye muscles
- B. Both near and distant vision
- C. Cloudiness in the eye lenses
- D. Intraocular pressure changes
Correct Answer: B
Rationale: The lenses are prescribed to correct the patient's near and distant vision. The nurse also may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data will not evaluate whether the patient's bifocals are effective.