Which assessment technique should the nurse implement when a...

Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?

A. Move the big toe up and down and ask in which direction the vibration is felt.
B. Place a tuning fork on the big toe and ask if the vibrations are felt.
C. Tap the client's cheek with the finger and determine if vibrations are felt.
D. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.

Correct Answer: B

Rationale: Placing a tuning fork on the big toe assesses vibration sense (via dorsal column pathways), not cranial nerves directly, but is the correct technique. Other options assess different sensations.

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The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?

A. Elderly clients react to pain the same way any other age group does.
B. The elderly client usually requires more pain medication.
C. Reaction to painful stimuli may be decreased with age.
D. The elderly client should use the Wong scale to assess pain.

Correct Answer: C

Rationale: Age-related sensory decline reduces pain perception in the elderly, affecting reporting. Pain reaction varies, more medication is not standard, and the Wong scale is pediatric.

The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.

A. Notify the health-care provider.
B. Check the client’s hemoglobin A1c.
C. Assess the client’s vision using the Amsler grid.
D. Teach the client about controlling blood glucose levels.
E. Determine where the spots appear to be in the client’s field of vision.

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

Rationale: 1) Notify HCP (urgent for possible diabetic retinopathy); 2) Determine spot location (assess severity); 3) Amsler grid (evaluate central vision); 4) Check HbA1c (assess control); 5) Teach glucose control (long-term management).

The nurse completed teaching the client with a corneal abrasion about proper care of the injury. Which statements indicate that the client understood the teaching? Select all that apply.

A. I should promptly report a sudden absence of pain.
B. I should keep my affected eye uncovered when up.
C. I should insert the eye drops 10 to 15 seconds apart.
D. I should leave the eye patch in place for 24 hours.
E. I will avoid rubbing my affected eye or the eye patch.

Correct Answer: D,E

Rationale: Patching the eye for 24 hours reduces irritation and promotes healing. Avoiding rubbing prevents reinjury. Sudden absence of pain, keeping the eye uncovered, and short intervals between drops are incorrect.

The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching?

A. The client must lie flat with the face down.
B. The head of the bed must be elevated 45 degrees.
C. The client should wear sunglasses when outside.
D. The client should avoid reading for three (3) weeks.

Correct Answer: A

Rationale: Face-down positioning maintains gas tamponade pressure on the retina, aiding reattachment. Elevation, sunglasses, and reading restrictions are secondary or incorrect.

The nurse is providing teaching on the home treatment of acute sinusitis. Which interventions should the nurse advise the client to implement? Select all that apply.

A. Take over-the-counter ranitidine.
B. Apply warm compresses to the face.
C. Use saline nasal spray as directed.
D. Take over-the-counter pseudoephedrine.
E. Spend time outdoors in the sunlight.

Correct Answer: B,C,D

Rationale: Applying warm compresses, using saline nasal spray, and taking a decongestant like pseudoephedrine relieve nasal and sinus congestion. Ranitidine treats dyspepsia, and sunlight exposure is unrelated to sinusitis.