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 with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
- A. Do not push or pull objects heavier than 50 pounds.
- B. Lie on the affected eye with two pillows at night.
- C. Wear glasses or metal eye shields at all times.
- D. Bend and stoop carefully for the rest of your life.
Correct Answer: C
Rationale: Wearing eye shields protects the eye post-cataract surgery, especially at night. Heavy lifting is restricted lighter, lying on the affected eye is avoided, and lifelong bending restrictions are excessive.
The client recovering at home following a stapedectomy for otosclerosis reports having dizziness. To decrease symptoms, which interventions should the nurse recommend? Select all that apply.
- A. Refrain from sudden movements.
- B. Avoid chewing on the affected side.
- C. Avoid lifting objects that are heavy.
- D. Minimize bending over at the waist.
- E. Restrict the intake of oral fluids.
Correct Answer: A,C,D
Rationale: Refraining from sudden movements, avoiding heavy lifting, and minimizing bending decrease dizziness by reducing fluid shifts in the inner ear. Chewing and fluid restriction do not affect dizziness.
The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene?
- A. Carefully remove the stick from the eye.
- B. Stabilize the stick as best as possible.
- C. Flush the eye with water if available.
- D. Place the young man in a high-Fowler's position.
Correct Answer: B
Rationale: Stabilizing the stick prevents further damage until surgical removal. Removing it risks bleeding, flushing is contraindicated, and positioning is secondary.
The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply.
- A. Do not touch the tip of the medication container to the eye.
- B. Apply gentle pressure on the outer canthus of the eye.
- C. Apply sterile gloves prior to instilling eyedrops.
- D. Hold the lower lid down and instill drops into the conjunctiva.
- E. Gently pat the skin to absorb excess eyedrops on the cheek.
Correct Answer: A,D,E
Rationale: Avoiding container contact prevents contamination, instilling into the conjunctiva ensures absorption, and patting excess drops maintains hygiene. Pressure on the outer canthus is incorrect (nasolacrimal duct pressure prevents systemic absorption), and sterile gloves are unnecessary.
A client complains of tinnitus and dizziness and has a diagnosis of Ménière's disease. She asks the nurse, 'What is the cause of Ménière's disease?' What is the nurse's best response?
- A. Ménière's disease is caused by a virus.'
- B. The cause of Ménière's disease is unknown.'
- C. Ménière's disease frequently follows a streptococcal infection.'
- D. It is hereditary. Both of your parents carried the gene for Ménière's disease.'
Correct Answer: B
Rationale: The exact cause of Ménière's disease is unknown, though it involves fluid imbalance in the inner ear.