Nokea
The patient tells the nurse that he is legally blind. In which way will this information impact the plan of care for this patient?
- A. The patient would be considered totally blind.
- B. This patient probably has some light perception, but no usable vision.
- C. This patient has some usable vision, which enables function at an acceptable level.
- D. The nurse would need to determine how this patient's visual impairment affects normal functioning.
Correct Answer: D
Rationale: Legal blindness' refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient.
You may also like to solve these questions
Which action should the nurse take when assisting a blind person to walk in an unfamiliar hospital environment?
- A. Discourage the use of the cane.
- B. Advise the patient to walk quickly.
- C. Describe the surroundings.
- D. Encourage the patient to ask for verbal cues.
- E. Place patient hand on nurse's shoulder or elbow.
Correct Answer: C,D,E
Rationale: The patient should be given verbal cues about the environment. Allow the patient to hold the nurse's shoulder or elbow while the nurse walks in front and encourage the use of a cane to let the patient 'examine' the boundaries and obstacles.
Which condition may cause conductive hearing loss.
- A. Buildup of cerumen
- B. Foreign bodies
- C. Otosclerosis of external auditory canal
- D. Trauma
- E. Exposure to ototoxic drugs
- F. Otitis media with effusion
Correct Answer: A,B,C,F
Rationale: Common causes of conductive hearing loss are buildup of cerumen and otitis media with effusion (escape of effusion). Other conditions that may result in conductive hearing loss are foreign bodies, otosclerosis, and stenosis of the external auditory canal. Sensorineural hearing loss is usually due to trauma, infectious processes, or exposure to ototoxic drugs.
Which action should a patient who has had a cataract repair avoid?
- A. The use of eye patches
- B. The use of sunglasses
- C. The lifting of heavy objects
- D. Reading for long periods of time
Correct Answer: C
Rationale: Postcataract patients should avoid any activity that increases the intraocular pressure, such as lifting heavy objects, stooping, and bending.
When the patient in the emergency room reports seeing flashing lights and a curtain down over the right eye, the nurse recognizes this as a symptom of which condition?
- A. Detached retina
- B. Macular degeneration
- C. Early sign of cataract
- D. Diabetic retinopathy
Correct Answer: A
Rationale: The standard symptom of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes.
One of the housekeepers splashes a chemical in the eyes. Which action should be the first priority?
- A. Transport to a health care provider immediately.
- B. Cover the eyes with a sterile gauze.
- C. Irrigate with H2O for 5 minutes.
- D. Irrigate with normal saline solution for 20 minutes.
Correct Answer: D
Rationale: Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure.