Sensory Questions

The 65-year-old client is diagnosed with macular degeneration. Which statement by the nurse indicates the client needs more discharge teaching? 1. "I should use magnification devices as much as possible." 2. "I will look at my Amsler grid at least twice a week." 3. "I am going to use low-watt light bulbs in my house." 4. "I am going to contact a low-vision center to evaluate my home."

#31. Magnifying devices used with activities such as threading a needle will help the client's visual sight; therefore, this statement does not indicate-the client needs more teaching.2. An Amsler grid is a tool to assess macular degeneration that often provides the earliest sign of a worsening of the condition. If the lines of the grid become distorted or faded, the client should call the ophthalmologist.*3. Macular degeneration is the most common cause of visual loss in people older than age60 years. Any intervention that can help increase vision should be included in the teaching such as bright lighting, not decreased lighting.*4. Low-vision centers will send representatives to the client's home or work to make recommendations about improving lighting, thereby improving the client's vision and safety. TEST-TAKING HINT: The test taker must be sure what the question is asking prior to looking at the answer options. This question is asking which statement indicates more teaching is needed. Therefore three (3) options will indicate that the client understands appropriate discharge teaching and only one (1) will indicate the client does not understand the teaching.

A client's relative asks the nurse what a cataract is. Which explanation should the nurse provide?] 1. An opacity of the lens 2. A thin film over the cornea 3. A crystallization of the pupil 4. An increase in the density of the conjunctiva

1 rationale: A cataract is a clouding (opacity) of the crystalline lens or its capsule. A thin film over the cornea, a crystallization of the pupil, and an increase in the density of the conjunctiva are not the pathophysiology related to cataracts.

The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the health care provider (HCP) has prescribed atropine sulfate and pilocarpine hydrochloride eye drops. The nurse should contact the HCP before the home visit for which reason? 1. Clarify the prescription for the atropine sulfate. 2. Clarify the prescription for the pilocarpine hydrochloride. 3. Determine the date of the scheduled follow-up HCP visit. 4. Determine the extent of the intraocular pressure caused by the glaucoma.

1. Clarify the prescription for the atropine sulfate. Rationale: Atropine sulfate is a mydriatic and cycloplegic medication that is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and cause increased intraocular pressure in the eye. Pilocarpine hydrochloride is a miotic agent used in the treatment of glaucoma. It is unnecessary to contact the HCP regarding the date for follow-up treatment. In fact, the client may know this date, which the nurse can ask about during the home care visit. It is unnecessary to know the extent of the intraocular pressure caused by the glaucoma in planning care for the client.

A client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client takes which action? 1. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid 2. Lies supine, pulls down on the lower lid, and puts the drop in the lower lid 3. Tilts the head back, pulls down on the lower lid, and puts the drop in the lower lid 4. Lies with head to the right, puts the drop in the inner canthus, and slowly turns to the left while blinking

1. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid Rationale: It is correct procedure for the client to lie down or sit with his or her head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward) and squeezes the bottle so that one drop falls into the sac. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. With the eye closed, the client squeezes the drop onto the inner canthus of the eye. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac.

Betaxolol eye drops have been prescribed for a client with glaucoma. The home health nurse preparing to visit the client develops a plan of care that includes monitoring for the side/adverse effects of this medication by taking which assessment action? 1. Monitoring body weight 2. Assessing the glucose level 3. Assessing peripheral pulses 4. Monitoring body temperature

1. Monitoring body weight Rationale: This medication is an antiglaucoma medication and a β-adrenergic blocker. The nurse assesses for evidence of heart failure manifested by dizziness, night cough, peripheral edema, and distended neck veins. Intake greater than output, weight gain, and decreased urine output also may indicate heart failure. Hypotension (manifested as dizziness), nausea, diaphoresis, headache, fatigue, and constipation or diarrhea also are potential systemic effects of the medication. Nursing interventions include monitoring body weight; periodically evaluating blood pressure for hypotension; and assessing the apical or radial pulse for strength, weakness, irregular heart rate, and bradycardia.

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching is effective? 1. "I should call the clinic if my eye begins to hurt." 2. "I am so glad that I can take a shower tomorrow. "3. "There will be bright flashes of light for a few days." 4. "My vision should show some improvement by tomorrow

1rationale:Pain after a cataract extraction and intraocular lens implant may indicate infection, increased intraocular pressure, or hemorrhage and should be reported immediately. Soap may irritate the eye, and showers or shampooing of the hair should be avoided as instructed. Seeing bright flashes of light is a symptom of retinal detachment and is not expected. Although rapid vision improvement may occur in some people, others may require several weeks to achieve improved visual acuity.

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that: 1 dilate the eye to prevent pressure from occurring." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

3. "The medication causes the pupil to constrict and will lower the pressure in the eye." Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

A 75-year-old male client has a history of macular degeneration. While he is in the hospital,the priority nursing goal will be: 1. To provide education regarding community services for clients with adult macular degeneration(AMD). 2. To provide health care related to monitoring his eye condition. 3. To promote a safe, effective care environment. 4. To improve vision.

3. AMD generally affects central vision.Confusion may result related to the changes in the environment and the inability to see the environment clearly. Therefore, providing safety is the priority goal in the care of this client. Educating him regarding community resources or monitoring his AMD may have been done at an earlier date or can be done after assessing his knowledge base and experience with the disease process. Improving his vision may not be possible.

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? 1. Doxycycline 2. Atropine sulfate 3. Acetylsalicylic acid 4. Diltiazem hydrochloride

3. Acetylsalicylic acid Rationale: Aspirin is contraindicated for GI bleeding and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have effects that are potentially associated with hearing difficulties.

Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side towardthe door. 4. Turn the head from side to side when walking.

4. To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. A patch does not address the problem of hemianopsia. Appropriate client positioning and placement of personal items will increase the client's ability to cope with the problem but will not affect safety.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.)A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine

A, B, EClients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.

When assisting a blind patient in ambulating to the bathroom, the nurse should a. take the patient by the arm and lead the patient slowly to the bathroom. b. have the patient place a hand on the nurse's shoulder and guide the patient. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care?A. "My leg might turn very white after the surgery." B. "I should be concerned if my foot turns blue." C. "I should report a fever or any drainage." D. "Warmness, redness, and swelling are expected."

APallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis

The nurse is assigned to all of these clients. Which client should be assessed first?A. The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago B. The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

AThe client who had PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.

A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1. Irrigate the eyes with water. 2. Come to the emergency department. 3. Call the primary health care provider (PHCP). 4. Irrigate the eyes with diluted hydrogen peroxide.

Answer: 1 Rationale: In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medical services personnel arrive. In the emergency department, the cleansing agent of choice is usually normal saline. Calling the PHCP and going to the emergency department delays necessary intervention. Hydrogen peroxide is never placed in the eyes. Test-Taking Strategy: Note the strategic word, immediate. Focus on the type of injury and eliminate options 2 and 3 because they delay necessary intervention. Next, eliminate option 4 because hydrogen peroxide is never placed in the eyes.

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the surgeon. 2. Reassure the client that this is normal. 3. Turn the client onto her or his operative side. 4. Administer the prescribed pain medication and antiemetic.

Answer: 1 Rationale: Severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased intraocular pressure and should be reported to the surgeon immediately. Options 2, 3, and 4 are inappropriate actions. Test-Taking Strategy: Note the strategic word, initial, and the word severe. Eliminate option 2 because this is not a normal condition. The client should not be turned to the operative side; therefore, eliminate option 3. From the remaining options, focusing on the strategic word will direct you to the correct option.

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the primary health care provider (PHCP). 4. Accompany the client to the emergency department.

Answer: 1 Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a PHCP and receive a thorough eye examination to rule out the presence of other eye injuries. Test-Taking Strategy: Focus on the strategic word, immediately. Recalling the principles related to initial treatment of injuries and noting the type of injury sustained will direct you to the correct option.

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

Answer: 1 Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 feet (6 meters) from the chart. Test-Taking Strategy: Remember that normal visual acuity as measured by a Snellen chart is 20/20 vision. This should assist in eliminating options 3 and 4, because they are comparable or alike in that they indicate standing at a distance of 40 feet (12 meters). From the remaining options, remember that it is best and most accurate to test each eye separately and then test both eyes together.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

Answer: 1, 3, 5, 6 Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon, because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over. Test-Taking Strategy: Focus on the subject, postoperative care following eye surgery. Recalling that the eye needs to be protected and that increased IOP is a concern will assist in determining the home care measures to be included in the plan.

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1. Apply an eye patch. 2. Perform visual acuity tests. 3. Irrigate the eye with sterile saline. 4. Remove the piece of wood using a sterile eye clamp.

Answer: 2 Rationale: If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist, because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. Test-Taking Strategy: Note the strategic word, initial, and note the word penetrating. This should indicate that a laceration has occurred and that interventions are directed at preventing further disruption of the integrity of the eye. The only option that will prevent further disruption is to assess visual acuity.

A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.

Answer: 2 Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo. Test-Taking Strategy: Focus on the subject, preventing vertigo. Note the relationship between vertigo and avoiding sudden head movements in the correct option.

A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

Answer: 2 Rationale: Tinnitus is the most common complaint of clients with otological problems, especially problems involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with problems of the inner ear. Test-Taking Strategy: Note the strategic word, most. Recalling the anatomy and the function of the inner ear will direct you to the correct option.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the primary health care provider (PHCP). 4. Instruct the client to sleep with the head of the bed flat.

Answer: 2 Rationale: Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the PHCP as an initial action. Flat positions may increase the pressure. Test-Taking Strategy: Focus on the subject, normal IOP, and note the strategic word, initial. Remember that normal IOP is between 10 and 21 mm Hg and the pressure may be higher in the morning.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1. Provide the client with materials on legal blindness. 2. Instruct the client that he or she may need glasses when driving. 3. Inform the client of where he or she can purchase a white cane with a red tip. 4. Inform the client that it is best to sit near the back of the room when attending lectures.

Answer: 2 Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness. Test-Taking Strategy: Focus on the subject, interpreting a Snellen chart result. Note the test result, 20/60, and recall the associated interventions for this result. Also, eliminate options 1 and 3, as they are comparable or alike, implying that the test results indicate blindness.

The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? 1. Document the finding. 2. Continue to monitor the drainage. 3. Notify the primary health care provider (PHCP). 4. Mark the drainage on the dressing and monitor for any increase in bleeding

Answer: 3 Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the PHCP, because this indicates hemorrhage. Options 1, 2, and 4 are inappropriate at this time. Test-Taking Strategy: Determine if an abnormality exists. Note the words, bright red. Since an abnormality does exist, eliminate options that state to document and continue to monitor because an action is needed.

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. Speak loudly but mumble or slur the words. 2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly.

Answer: 3 Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear. Test-Taking Strategy: Focus on the subject, presbycusis and the effective method to communicate. Visualize each of the communication techniques to direct you to the correct option.

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.

Answer: 3 Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear. Test-Taking Strategy: Focus on the subject, an effective communication technique for the hearing impaired. Remember that it is important to speak in a normal tone.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.

Answer: 3 Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of her or his life. Options 1, 2, and 4 are not accurate instructions. Test-Taking Strategy: Focus on the subject, client teaching for glaucoma. Recalling that medications are an integral component of the treatment plan will assist in directing you to the correct option.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

Answer: 4 Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract. Test-Taking Strategy: Note the strategic word, early. Remember the pathophysiology related to cataract development. As a cataract develops, the lens of the eye becomes opaque. This description will assist in directing you to the correct option.

Which precaution is most important for the nurse to teach a 62-year-old client newly diagnosed with early-stage dry age-related macular degeneration? A. Quit smoking B. Quit drinking alcoholic beverages C. Eat more dark green, red, and yellow vegetables D. Wear dark glasses whenever he or she is outside or in bright interior lighting environments

Answer: A Rationale: Dry AMD is more common and progresses at a faster rate among smokers than among nonsmokers. Thus, quitting smoking can slow the rate of AMD progression. Avoiding alcohol and bright light (even ultraviolet light) is not related to AMD development or progression. Although increasing long-term dietary intake of antioxidants, vitamin B12, and the carotenoids lutein and zeaxanthin that are found in green, red, and yellow vegetables is thought to help slow the progression of AMD, the effects are not as profound as quitting smoking.

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds

Answer: A, D, E Rationale: Any action that would increase pressure in the eye should be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects. Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.

The nurse is teaching a client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? A. "I must wait 10 to 15 minutes between different eyedrop medications." B. "I must press on the inside of my eye to prevent washout." C. "It is important to not skip a dose." D. "These eyedrops will not cure my glaucoma."

Answer: B Rationale: Pressing on the inside of the eye after instillation of eye medication prevents systemic absorption of the drug. To avoid washout, the client should wait 10 to 15 minutes between eyedrop medications. Skipping a dose will not exacerbate the client's glaucoma. Medication will not cure glaucoma, but it will control its progression.

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? A. Burning in the eye B. Inability to differentiate colors C. Increased sensitivity to light D. Gradual vision changes

Answer: D Rationale: Gradual vision changes are an indication of increased intraocular pressure. A burning sensation in the eye usually indicates inflammation and/or infection. An inability to differentiate colors is an early sign of cataracts. An increased sensitivity to light might be a sign of a corneal abrasion.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure?A. Ankle-brachial index B. Dye allergy C. Pedal pulses D. Gag reflex

CPriority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for?a. An acute obstruction in the vessels of the legsb. Peripheral vascular problems in both legsc. Diabetesd. Calcium deficiency

b. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

A significant cause of venous thrombosis is:a. Altered blood coagulationb. Stasis of bloodc. Vessel wall injuryd. All of the above

D. All of the above

Which medication, if prescribed for the client with glaucoma, should the nurse question? 1. Betaxolol 2. Pilocarpine 3. Erythromycin 4. Atropine sulfate

4. Atropine sulfate Rationale: Options 1 and 2 are miotic agents used to treat glaucoma. Option 3 is an antiinfective medication used to treat bacterial conjunctivitis. Atropine sulfate is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess?A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

AClaudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

After a left cataract extraction, a client reports severe discomfort in the operated eye. The nurse concludes that this problem may be caused by which condition? 1. Hemorrhage into the eye 2. Expected postoperative discomfort 3. Isolation related to sensory deprivation 4. Pressure on the eye from the protective shield

1 rationale:Acute postoperative pain is a sign of increased intraocular pressure and is caused by hemorrhaging; this is a medical emergency. Postoperative discomfort usually is minimal. Isolation and sensory deprivation will not occur because only one eye is patched. The shield may be slightly uncomfortable but will not cause severe discomfort.

The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? Select all that apply . 1. Do not blow your nose. 2. Remain flat for three hours. 3. Eat a soft diet for two days. 4. Breathe and cough deeply. 5. Avoid bending from the waist.

1, 5 rationale:The client needs to avoid activities that cause a sudden rise in intraocular pressure, such as bending from the waist, blowing the nose, sneezing, and coughing. It is not necessary to remain flat in bed for three hours after surgery, and the diet is not restricted.

Betaxolol eye drops have been prescribed for a client with glaucoma. The nurse monitoring this client for side/adverse effects of the medication would place highest priority on which assessment? 1. Pulse rate 2. Blood glucose 3. Respiratory rate 4. Oxygen saturation

1. Pulse rate Rationale: Betaxolol is a beta-blocking agent as well as an antiglaucoma medication. Nursing assessments include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. The nurse also assesses for evidence of heart failure as manifested by dizziness, night cough, peripheral edema, and distended neck veins.

Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do? 1. Provide some dry crackers to eat 2. Administer the prescribed antiemetic 3. Explain that this is expected after surgery 4. Encourage deep breathing until the nausea subsides

2 rationale:An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Aggressive intervention is required rather than dry crackers. Explaining that this is expected after surgery is incorrect. Deep breathing will not minimize nausea; aggressive intervention is required to prevent vomiting.

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery? 1. remain flat for three hours 2. eat a soft diet for two days 3. breathe and cough deeply 4. avoid bending from the waist

4 rationale:Bending increases intraocular pressure and must be avoided. Remaining flat for three hours and eating a soft diet for two days are not necessary. Coughing deeply increases intraocular pressure and is contraindicated.

The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the ear drops correctly, the mother needs to take which action? 1. Pull up and back on the earlobe and direct the solution toward the eardrum. 2. Pull down and back on the auricle and direct the solution toward the eardrum. 3. Pull up and back on the auricle and direct the solution toward the wall of the canal. 4. Pull down and back on the earlobe and direct the solution toward the wall of the canal.

4. Pull down and back on the earlobe and direct the solution toward the wall of the canal. Rationale: The infant should be turned onto the side, with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the mother pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal.

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply.) A. "You will need to wear a patch on your eye for several weeks after the surgery." B. "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." C. "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." D. "Bring sunglasses with you on the day of your procedure." E. "You might experience a lot of bruising and swelling around the eye."

Answer: B, C, D Rationale: The client will have multiple eyedrops to use after surgery and should be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eyedrops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure. A patch is required after surgery only if a risk for injury is present. Cataract surgery does not cause bruising and swelling post-surgery.

A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? A. Increased tearing B. Itching of the eye C. Reduction in vision D. Swollen eyelid

Answer: C Rationale: A reduction in vision after cataract surgery indicates a problem, and the client should notify the provider immediately. Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.

A nurse performs an assessment of a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which of the following symptoms? a) loss of peripheral vision b) blurred central vision c) increased clarity when looking at objects d) clear vision when reading

B-The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients might complain of visual distortion, usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)?A. "Elevate your legs above heart level to prevent swelling." B. "Inspect your legs daily for brownish discoloration around the ankles." C. "Walk to the point of leg pain, then rest, resuming when pain stops." D. "Apply a heating pad to the legs if they feel cold."

CExercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic?A. "Are you afraid you will not be able to work?" B. "If you control your diabetes, you can avoid amputation." C. "Your concerns are valid; we can review some steps to limit disease progression." D. "What about the situation concerns you most?"

CIt is important to validate the client's concern and offer needed information. Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern.

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.)A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

D, E, FPain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.