The nurse who is at a local park sees a young man on the gro...

The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene?

A. Carefully remove the stick from the eye.
B. Stabilize the stick as best as possible.
C. Flush the eye with water if available.
D. Place the young man in a high-Fowler's position.

Correct Answer: B

Rationale: Stabilizing the stick prevents further damage until surgical removal. Removing it risks bleeding, flushing is contraindicated, and positioning is secondary.

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The client recovering at home following a stapedectomy for otosclerosis reports having dizziness. To decrease symptoms, which interventions should the nurse recommend? Select all that apply.

A. Refrain from sudden movements.
B. Avoid chewing on the affected side.
C. Avoid lifting objects that are heavy.
D. Minimize bending over at the waist.
E. Restrict the intake of oral fluids.

Correct Answer: A,C,D

Rationale: Refraining from sudden movements, avoiding heavy lifting, and minimizing bending decrease dizziness by reducing fluid shifts in the inner ear. Chewing and fluid restriction do not affect dizziness.

A family member of the client undergoing cataract surgery asks the nurse if there are ways to prevent cataracts. Which recommendations should the nurse suggest? Select all that apply.

A. Wear sunglasses that limit ultraviolet light penetration.
B. Wear sunscreen with a high protection factor number.
C. Wear eye protection if there is any risk for eye injury.
D. Avoid activities and reading in dimly lit environments.
E. Eat foods that are high in vitamin C, such as oranges.

Correct Answer: A,C

Rationale: Limiting eye exposure to UV light has been found to decrease the risk for cataracts. Avoiding trauma to the eye has been found to decrease the risk for cataracts. Sunscreen is applied to the skin, not the eyes. Straining the eyes to read does not lead to cataract formation. There is no evidence that nutrition prevents or delays progression of cataracts.

A stroke victim regains consciousness three days after admission. She has right-sided hemiparesis and hemiplegia and also has expressive aphasia. She becomes upset when she is unable to say simple words. The best approach for the nurse is to do which of the following?

A. Stay with her and give her time and encouragement in attempting to speak.
B. Say, 'I'm sure you want a glass of water. I'll get it for you.'
C. Say, 'Don't get upset. You rest now and I'll come back later and try to talk to you then.'
D. Encourage her attempts and say, 'Don't worry, it will get easier every day.'

Correct Answer: A

Rationale: Staying with the client and offering encouragement supports her attempts to speak, fostering communication and emotional support.

The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?

A. Ensure the client's room temperature is cool.
B. Talk louder to make sure the client hears clearly.
C. Complete the admission as fast as possible.
D. Provide extra orientation to the surroundings.

Correct Answer: D

Rationale: Extra orientation helps elderly clients with sensory deficits adjust to new environments, enhancing safety. Cool rooms, loud talking, and rushed admissions are less effective.

The nurse is examining the client's ear using an otoscope and sees the image illustrated. Which documentation by the nurse is best?

A. Tympanic membrane ruptured, no excessive cerumen
B. External ear canal showing no lesions or drainage
C. Tympanic membrane cone of light reflex distorted
D. Bony landmarks prominent on tympanic membrane

Correct Answer: C

Rationale: The tympanic membrane shown is reddened, and the cone of light is distorted, indicating increased pressure behind the tympanic membrane. The membrane is intact, the external canal is not shown, and bony landmarks are not prominent.