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Which action is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye?
- A. Assess eye, do not remove object.
- B. Cover both eyes with an eye shield or cup.
- C. Check for the irregularity of the pupil.
- D. Obtain medical attention immediately.
Correct Answer: C
Rationale: The patient should be placed on his back to prevent loss of the aqueous humor, assessment of the eye for the location of the object and whether the pupil is regular, cover the eye to prevent movement, and obtain medical attention immediately.
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Which report made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts?
- A. Pain in the eyes
- B. Difficulty driving at night
- C. Loss of peripheral vision
- D. Dry eyes
Correct Answer: B
Rationale: Blurring of vision and difficulty driving at night is often the first subjective symptom reported by a patient who has cataracts.
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.
The surgical incision into the eardrum with either a knife or a heated wire loop to relieve pressure in the middle ear is a(n) ___
Correct Answer: myringotomy
Rationale: The opening of the eardrum with a specialized knife or a heated wire loop to relieve pressure in the middle ear is a myringotomy.
The nurse will advise the patient to take which action following a left vitrectomy?
- A. Remain flat in bed for 48 hours.
- B. Position self in a face-down position for 4 to 5 days.
- C. Assume a side-lying position with the left side down for 3 days.
- D. Keep head upright and cushioned with pillows for 24 hours.
Correct Answer: B
Rationale: Following a vitrectomy, the patient must assume a face-down position or turn the face to the right side for 4 to 5 days.
The nurse expects to see which aspect in the plan of care following a tympanoplasty?
- A. Elevating head of bed with operative side facing upward
- B. Enforcing bed rest for 72 hours
- C. Frequent turning, coughing, and deep breathing
- D. Continuous irrigation of the ear canal with antibiotic solutions
Correct Answer: A
Rationale: Postoperative management for patients who have had a tympanoplasty consists of bed rest until the next morning. The head of the bed is elevated 40 degrees, and the operative side faces upward.