Nokea
Which situation makes the nurse suspect the client has glaucoma?
- A. An automobile accident because the client did not see the car in the next lane.
- B. The cake tasted funny because the client could not read the recipe.
- C. The client has been wearing mismatched clothes and socks.
- D. The client ran a stoplight and hit a pedestrian walking in the crosswalk.
Correct Answer: A
Rationale: Not seeing a car in the next lane suggests peripheral vision loss, a hallmark of glaucoma. Taste, color perception, and stoplight issues are unrelated.
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The client tells the nurse, 'I have something under my upper eyelid and don't recall how it happened.' The client has no eye redness or pain and no changes in vision. Which intervention should the nurse implement?
- A. Notify the client's health care provider for guidance.
- B. Flush the client's eye with sterile saline for 10 minutes.
- C. Evert the upper lid with a cotton-tipped applicator for examination.
- D. Place an eye patch, taping from the outside of the eye to the inside.
Correct Answer: C
Rationale: Since the client has no pain or vision changes, the nurse should assess by everting the upper eyelid with a cotton-tipped applicator to visualize the issue. Contacting the HCP, flushing, or patching should follow assessment.
A 27-year-old woman is admitted to the hospital complaining of numbness in both legs, difficulty walking, and double vision of one week in duration. Multiple sclerosis is suspected. Orders include bed rest with bathroom privileges, brain scan, EEG, lumbar puncture, adrenocorticotropic hormone (ACTH) 40 units intramuscularly (IM) bid x 3 days, then 30 units IM bid x 3 days, then 20 units IM bid x 3 days; and passive range of motion (ROM) progressing to active ROM as tolerated. In planning care for this client, which activity is most important to include?
- A. Encouraging her to perform all care activities for herself
- B. Frequent ambulation to retain joint mobility
- C. Scheduling frequent rest periods between physical activity
- D. Feeding the client to reduce energy needs
Correct Answer: C
Rationale: Frequent rest periods are essential to manage fatigue, a common symptom in multiple sclerosis, while supporting activity as tolerated.
The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include?
- A. Limit oral fluid intake to 1000 mL daily.
- B. Eat foods that are high in omega-3 fatty acids.
- C. Have annual eye exams with an eye specialist.
- D. Use timolol maleate eye drops when feeling eye pressure.
Correct Answer: C
Rationale: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction and omega-3 fatty acids do not affect intraocular pressure. Elevated intraocular pressure cannot be felt, and timolol maleate should be used as prescribed.
The client with glaucoma is prescribed pilocarpine hydrochloride 1% eye drops to both eyes four times per day. The nurse knows that this medication has which expected action?
- A. Increases the outflow of aqueous humor
- B. Improves vision in dimly lit environments
- C. Increases production of aqueous humor
- D. Increases ability of both pupils to dilate
Correct Answer: A
Rationale: Pilocarpine hydrochloride is a cholinergic agent used to treat glaucoma. It causes miosis (pupillary constriction), which then increases the angle of the channel in the anterior chamber of the eye. This improves the outflow of aqueous humor. It does not improve vision in dim light, increase aqueous humor production, or cause pupil dilation.
The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?
- A. Ensure the client's room temperature is cool.
- B. Talk louder to make sure the client hears clearly.
- C. Complete the admission as fast as possible.
- D. Provide extra orientation to the surroundings.
Correct Answer: D
Rationale: Extra orientation helps elderly clients with sensory deficits adjust to new environments, enhancing safety. Cool rooms, loud talking, and rushed admissions are less effective.