SENSORY
A nurse is caring for a client following cataract surgery. Which of the following comments from the clients should the nurse report to the client's provider?
"I need something for the pain in my eye. I can't stand it." - following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage - itching is common after cataract surgery. The nurse should remind the client not to rub or place pressure on the eyes - clients who wear an eye patch lose their depth perception and part of their peripheral vision, temporarily decreasing visual acuity - the client may find that exposure to bright lights is uncomfortable after cataract surgery. Wearing sunglasses can prevent most of the client's discomfort
A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
"I will clean the hearing aids with alcohol wipes." - alcohol use can break down the mechanism of the hearing aids. The client should follow the manufacturer's instructions, which usually include using a soft cloth to remove cerumen and other debris and never immersing them in water - hairspray residue makes hearing aids oily and greasy, which can damage them - if the client wears hearing aids for 10 to 12 hr a day, the batteries should lasts about a week. The client should keep additional batteries nearby - a whistling sound when the client cups her hand over an wear with a hearing aid in place means that the battery is functioning
A nurse is teaching an older adult client who has DM about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
"Maintain stable blood glucose levels." - keeping blood glucose under control is the client's best protection against long-term complications of diabetes, since increasing blood sugar contributes to neuropathic disease, and microvascular complications such as retinopathy and nephropathy, as well as macrovascular complication - eye exams once per year is an important practice that helps with early detection of retinopathy or other visual complications. It does not prevent them, however - examining your feet carefully everyday is an important measure for client who has peripheral neuropathy to use to detect skin alterations, but it does not prevent neuropathy - constant use of compression stockings can impair circulation and increase the risk for complications rather than protect against them. Clients who have diabetes should not wear them routinely
A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?
"Restrict lifting objects greater than 10 pounds." - the nurse should instruct the client to restrict lifting objects greater than 10 pounds to reduce the risk for increased intraocular pressure - the nurse should instruct the client to take acetaminophen for discomfort. Aspirin inhibits platelet aggregation and can increase the risk for bleeding - the nurse should instruct the client to report a reduction of vision following the procedure - the nurse should instruct the client to apply a cool compress for discomfort
A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include?
"Vision will be greatly improved on the day of surgery." - vision should be greatly improved on the day of surgery. This information should be included in teaching - bloodshot eyes are an expected finding on the day of surgery - cold compresses should be applied to the eye - photophobia is not an expected finding and should be immediately reported to the provider
A provider prescribes quetiapine 50 mg PO divided equally every 12 hr for 3 days. Available is quetiapine 25 mg tablets. How many tablets should the nurse administer per dose on day 3?
1 tablet
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
determine if the client is using hearing aids - the first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning - the nurse should speak in his usual tone of voice to optimize the client's ability to hear and comprehend. However, there is another action the nurse should take first - the nurse should stand directly in front of the client to optimize the client's ability to hear and comprehend, however, there is another action the nurse should take first
A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?
perforated tympanic membrane - the client has manifestation of otitis media with a perforated tympanic membrane (eardrum). Ear plan is reduced when fluid and pus drain from the eardrum due to the perforation - manifestation of mastoiditis include pain and swelling behind the ear, fever, hearing loss, and ear drainage - manifestations of Meniere's disease include tinnitus, hearing loss, vertigo, and nystagmus - acoustic neuroma is a benign tumor of the right cranial nerve. Manifestations include tinnitus, and hearing loss
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
scatter rugs are present in the kitchen - scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision - electrical cords along the wall are not a safety hazard and are out of the way to prevent the client from tripping on them - handrails present in the bathroom are not a safety risk and can prevent the client from falling - microwave ovens are a safer way of cooking than a standard stove for an individual who has impaired vision
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?
the client should wear dark glasses while outdoors - the nurse should instruct the client and his spouse that he should wear dark glasses when outside or in bright light until pupil reaction returns - the nurse should instruct the client to avoid NSAIDs, such as ibuprofen, as these can cause bleeding at the surgical site. The client should use acetaminophen, along with cool compresses, to treat discomfort - the nurse should instruct the client that creamy white drainage is an expected finding following cataract surgery. Drainage that is green or yellow in color should be reported to the provider immediately - the nurse should remind the client that mild itching is normal occurrence following cataract surgery. The client should be instructed to contact the provider if eye pain occurs with nausea and vomiting as this can indicate an increase in intraocular pressure
A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?
the medication should be applied on a regular schedule for the rest of the client's life - medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or decrease its production, or both. The client must continue the eye drops on an uninterrupted basis for life to maintain intraocular pressure at an acceptable level - treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen the client's condition - the client needs to take the medication daily to reduce intraocular pressure and preserve remaining eyesight