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The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patients health education?
- A. The need to limit exposure to bright light
- B. The need to maintain a low Fowlers position when removing the prosthesis
- C. The need to perform thorough hand hygiene before handling the prosthesis
- D. The need to apply antiviral ointment to the prosthesis daily
Correct Answer: C
Rationale: Hand hygiene prevents infection when handling an ocular prosthesis. Bright light, low Fowlers position, and antiviral ointment are not relevant to prosthesis care.
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A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this patients psychosocial needs, what nursing action is most appropriate?
- A. Encourage the patient to focus on her use of her other senses.
- B. Assess and promote the patients coping skills during interactions with the patient.
- C. Emphasize that her lifestyle will be unchanged once she adapts to her vision loss.
- D. Promote the patients hope for recovery.
Correct Answer: B
Rationale: Promoting coping skills supports psychosocial adjustment to vision loss from macular degeneration. Focusing on other senses or promising unchanged lifestyle may minimize the loss, and recovery is unlikely.
The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?
- A. Assess the patients vision using a Snellen chart.
- B. Determine whether the patient is able to see the nurses hand motion.
- C. Perform a detailed examination of the patients external eye structures.
- D. Palpate the patients periocular regions.
Correct Answer: B
Rationale: If the patient cannot count fingers, testing hand motion detection is the next step to assess visual acuity. Snellen charts require better vision, and external exams or palpation do not measure acuity.
The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?
- A. Provide instructions in simple, clear terms.
- B. Introduce herself in a firm, loud voice at the doorway of the room.
- C. Lightly touch the patients arm and then introduce herself.
- D. State her name and role immediately after entering the patients room.
Correct Answer: D
Rationale: Stating name and role first identifies the nurse without startling the blind patient. Simplifying instructions or using a loud voice is unnecessary, and touching before introducing may cause discomfort.
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
- A. Assess the patient for any previous inability to self-manage medications.
- B. Ask the patient to demonstrate the instillation of her medications.
- C. Determine whether the patient can accurately describe the appropriate method of administering her medications.
- D. Assess the patients functional status.
Correct Answer: B
Rationale: Demonstrating eye drop instillation confirms the patient's ability to self-administer safely. Descriptions, past management, or functional status are less direct assessments.
A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate?
- A. Holding the next dose and notifying the physician
- B. Treating the patient for an allergic reaction
- C. Suggesting that the patient put on her glasses
- D. Explaining that this is an expected adverse effect
Correct Answer: D
Rationale: Blurred vision is a common, temporary side effect of pilocarpine due to pupil constriction. It does not indicate an allergy, require glasses, or necessitate withholding the dose.