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 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 completes an assessment of the older adult client. Which disorder should the nurse associate with the finding illustrated?
- A. Glaucoma
- B. Arcus senilis
- C. Cataract
- D. Mydriasis
Correct Answer: C
Rationale: The illustration shows opacity of the lens of the eye. The nurse should associate this finding with a cataract. Glaucoma causes increased pressure within the eye and is not visible. Arcus senilis is a bluish-white ring within the outer edge of the cornea, which is not present in this illustration. Mydriasis is constriction of the pupil, which is not present in the illustration.
An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss?
- A. Place frequently used items on the affected side
- B. Position her so that her affected side is toward the activity in the room
- C. Encourage her to turn her head from side to side to scan the environment on the affected side
- D. Stand on the affected side while assisting her in ambulating
Correct Answer: C
Rationale: Encouraging head turning to scan the environment compensates for right homonymous hemianopia by ensuring awareness of the affected side.
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 nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact?
- A. The client can identify cold and hot on the face.
- B. The client does not have any tongue tremor.
- C. The client has no ptosis of the eyelids.
- D. The client is able to identify a peppermint smell.
Correct Answer: D
Rationale: Cranial nerve I (olfactory) is assessed by identifying smells like peppermint. Temperature sensation (trigeminal), tongue movement (hypoglossal), and ptosis (oculomotor) involve other nerves.