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 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.

The nurse is assessing a client and performs a whisper test. Which should the nurse implement? Rank in order of performance.

A. Have the client cover the ear not being tested.
B. Stand 12 to 24 inches to the side of the client.
C. Explain to the client to repeat what the nurse says.
D. Repeat the test for the opposite ear.
E. Ask the client if he/she is willing to participate in the test.

Correct Answer: E,C,B,A,D

Rationale: 1) Ask for participation (consent); 2) Explain the procedure; 3) Position 12–24 inches away; 4) Cover the non-tested ear; 5) Repeat for the opposite ear.

The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching?

A. Instruct the client not to take any over-the-counter pain medication.
B. Encourage the client to apply cold packs to the affected ear.
C. Tell the client to call the HCP if an abrupt relief of ear pain occurs.
D. Wear a protective ear plug in the affected ear.

Correct Answer: C

Rationale: Abrupt pain relief in otitis media may indicate tympanic membrane rupture, requiring HCP notification. OTC pain meds are safe, cold packs are less effective, and ear plugs are unnecessary.

The client asks the nurse about symptoms associated with retinal detachment. Which symptoms should the nurse identify? Select all that apply.

A. Seeing bright flashes of light
B. Shooting, throbbing eye pain
C. Severe frontal headache
D. Diminished visual acuity
E. Seeing floating dark spots in the vision field

Correct Answer: A,D,E

Rationale: As the choroid and retina partially separate, the client notices flashes of light, decreased vision, and floating dark spots. Pain is not associated with retinal detachment due to few pain fibers in the retina. Headache is not associated with retinal detachment.

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.