Nokea
The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the drops are used to anesthetize the eye if eye pain is experienced. What action should the PN implement?
- A. Document in the chart that the client understands the correct action and use of eye drops
- B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common
- C. Reteach the client about the action of the eye drops to decrease pressure in the eyes
- D. Explain to the client that the eye drops do not anesthetize the eyes but reduce pressure
Correct Answer: C
Rationale: Pilocarpine eye drops are used to reduce intraocular pressure in glaucoma, not to anesthetize the eye. The PN should reteach the client about the purpose of the medication to ensure proper use and understanding, which is crucial for effective treatment. Choice A is incorrect because just documenting understanding without addressing the client's misconception is not enough. Choice B is incorrect as it provides incorrect information about the purpose of the eye drops and may lead to further misunderstanding. Choice D is incorrect as it provides inaccurate information stating that the drops provide pain relief, which is not their primary purpose.
You may also like to solve these questions
The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?
- A. Altered sensory perception
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct Answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.
Patients are coming into the emergency room as a result of an apartment house fire. You are examining a patient who is in distress but has no visible burn marks. You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?
- A. Singed nasal hairs
- B. Conjunctivitis
- C. Hoarseness
- D. Clear sputum
Correct Answer: D
Rationale: Clear sputum would not be associated with inhalation burns. Inhalation burns typically present with symptoms like singed nasal hairs, conjunctivitis, hoarseness, and possibly soot in sputum due to smoke inhalation. Clear sputum suggests that there is no significant inflammation or injury to the respiratory tract, which is not consistent with the typical findings in inhalation burns. The other choices are associated with inhalation burns: singed nasal hairs can occur due to exposure to hot air or gases, conjunctivitis can result from irritating substances in smoke, and hoarseness can be due to airway irritation.
When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?
- A. Antiseptic cream
- B. Petroleum jelly
- C. Cornstarch
- D. Stomadhesive
Correct Answer: D
Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.
What is the first action a healthcare professional should take when a patient's nasogastric (NG) tube becomes clogged?
- A. Flush the tube with water
- B. Reposition the patient
- C. Attempt to aspirate the clog with a syringe
- D. Administer a medication to dissolve the clog
Correct Answer: C
Rationale: When a patient's nasogastric (NG) tube becomes clogged, the first action to take is to attempt to aspirate the clog with a syringe. This is a standard and initial step to clear the blockage in the tube. Flushing the tube with water (Choice A) may not address the specific clog; repositioning the patient (Choice B) is not directly related to clearing the tube. Administering a medication to dissolve the clog (Choice D) should only be considered after simpler methods like aspiration have been attempted.
The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?
- A. Document the lacerations in the client's record
- B. Report findings to the supervisor for referral to adult protective services
- C. Ask the daughter who has been taking care of the client on a daily basis
- D. Apply dry dressings after cleansing the wounds
Correct Answer: B
Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.