Chapter 64 My Nursing Test Banks

Osborn,_2e
Chapter 64

Question 1

Type: MCSA

Which patient statement would the nurse evaluate as indicating problems with accommodation?

1. I feel blinded by sunlight.

2. I cant tell the difference between colors as well as I once did.

3. I have trouble seeing at night.

4. I am having trouble reading the newspaper.

Correct Answer: 4

Rationale 1: The pupil controls the amount of light entering the eye. This is not a problem with accommodation.

Rationale 2: Color vision is a function of the rods and cone receptors in the retina. Accommodation is not related to color vision.

Rationale 3: Problems seeing at night may be due to cataracts or macular degeneration. It is not a problem with accommodation.

Rationale 4: Accommodation is the ability to focus from distant to near images.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-1

Question 2

Type: MCSA

A patients eye examination reveals limited central vision. The nurse would conduct further assessment for problems with which structure?

1. Sclera

2. Lens

3. Macula

4. Extraocular muscles

Correct Answer: 3

Rationale 1: The sclera is the outer protective layer of the eyeball that helps maintain its shape. Changes in the sclera would not specifically affect central vision.

Rationale 2: The lens is the focusing structure of the eye. Dysfunction of the lens would cause problems with all vision, not just central vision.

Rationale 3: The center of the retina, called the macula, is where the greatest numbers of cone receptors are located for central and color vision.

Rationale 4: The extraocular muscles move the eyeball. They help the patient fixate on an object but are not associated with central vision.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-1

Question 3

Type: MCSA

A patient complains that sometimes there appears to be gnats in the field of vision. The nurse would interpret this statement to mean that

the patient has which visual change?

1. Conjunctivitis

2. Floaters

3. Strabismus

4. Nystagmus

Correct Answer: 2

Rationale 1: Conjunctivitis is an inflammation of the conjunctiva. The main symptom is a discharge from the eyes.

Rationale 2: The vitreous gel is made up mainly of water with a collagen framework. The network can be aggregated by vitreous collapse due to aging and form opacities that cast shadows on the retina. These shadows are referred to as floaters. The patient may describe seeing gnats or a fine filament floating in the line of sight.

Rationale 3: Strabismus is a functional misalignment of the extraocular muscles that causes the eyes not to focus together.

Rationale 4: Nystagmus is an involuntary tremor or jerky movement of the eyeball.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-1

Question 4

Type: MCSA

The nurse is conducting assessment of a patients eye. Which instrument would the nurse obtain to measure intraocular pressure?

1. Snellen chart

2. Ophthalmoscope

3. Tonometer

4. Penlight

Correct Answer: 3

Rationale 1: The Snellen acuity chart is used to measure visual acuity.

Rationale 2: An ophthalmoscope is used to view the fundus of the eye by viewing through the pupil.

Rationale 3: A tonometer is used to measure the intraocular pressure.

Rationale 4: A penlight is used for external examination of the eye.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-2

Question 5

Type: MCSA

A patient has been diagnosed with primary glaucoma. What information would the nurse provide about this condition?

1. It was probably caused by a congenital anomaly in the structure of the eye.

2. Primary glaucoma is not as serious as other forms of glaucoma.

3. The disorder has no relation to other ocular conditions.

4. This condition is the result of conjunctival infections in childhood.

Correct Answer: 3

Rationale 1: A congenital anomaly is one cause of secondary, not primary, glaucoma.

Rationale 2: Glaucoma is always serious and can cause blindness because the increased intraocular pressure can cause optic nerve changes.

Rationale 3: Primary glaucoma is not related to other ocular conditions.

Rationale 4: Primary glaucoma is not related to any other ocular condition.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-1

Question 6

Type: MCSA

The nurse is caring for a patient newly diagnosed with glaucoma. The patient is asymptomatic except for increased intraocular pressure detected during a routine eye examination. When developing a plan of care, which intervention should have the highest priority?

1. Assess for fall injuries.

2. Discuss risk factors for developing glaucoma.

3. Consider home maintenance issues.

4. Stress the importance of compliance with the glaucoma eyedrop regimen.

Correct Answer: 4

Rationale 1: Assessing for fall injuries is more relevant to patients who already have vision loss.

Rationale 2: Discussion of risk factors is important, but the patient has already been diagnosed.

Rationale 3: Considering home maintenance issues is more relevant to patients who already have vision loss.

Rationale 4: All the interventions should be part of a nursing care plan for a patient with glaucoma. However, this patient is asymptomatic and has not suffered any vision loss. To prevent vision loss, patient compliance with the use of glaucoma eyedrops to reduce the intraocular pressure should be given the highest priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 64-2

Question 7

Type: MCSA

Phenylephrine (Neo-Synephrine) is administered to a patient before a diagnostic procedure. What should patient education about this medication include?

1. Driving may be difficult.

2. The eyes may be red for one or two days.

3. Tears will be yellow.

4. Sunlight will improve vision.

Correct Answer: 1

Rationale 1: Phenylephrine causes pupillary dilation. The nurse should inform the patient that driving with eyes dilated may cause difficulty, especially on a sunny day.

Rationale 2: Eye redness is a temporary condition and should clear in a short time. Eyes treated with latanoprost may be red for 812 weeks.

Rationale 3: Fluorescein sodium causes tears to appear yellow.

Rationale 4: Patients should be instructed to wear sunglasses to block ultraviolet (UV) exposure. The pupils are unable to react to or decrease the amount of light entering the eye.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-4

Question 8

Type: MCSA

A patient comes into the clinic complaining of sudden onset of black spots and a curtain dropping in the right eye. The nurse would conduct additional assessment for which condition?

1. Detached retina

2. Conjunctivitis

3. Endophthalmitis

4. Cataract

Correct Answer: 1

Rationale 1: Flashes of light, floaters, or the sensation of a curtain being drawn over the eye are indicators of retinal detachment.

Rationale 2: Conjunctivitis presents with pain, redness, and possible discharge.

Rationale 3: Endophthalmitis generally presents with blurred vision, eye pain, and pus in the eye.

Rationale 4: Cataracts are slowly progressive and manifest as problems with lights and glare.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-1

Question 9

Type: MCSA

A patient with an ectropion continues to experience eye dryness and corneal abrasions. The nurse would reinforce teaching about which treatment option?

1. Corrective surgery

2. Corrective lenses

3. UV protective sunglasses

4. Corneal transplant

Correct Answer: 1

Rationale 1: With ectropion, surgery may be performed to correct the defect, reduce the risk of damage to the eye, and improve cosmetic appearance.

Rationale 2: Corrective lenses would not be beneficial in correcting this condition.

Rationale 3: UV protective sunglasses would not be beneficial in correcting this condition.

Rationale 4: Corneal transplant is not indicated in correcting this condition.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-2

Question 10

Type: MCSA

An elderly patient is being discharged after having a cataract removed during same-day surgery. The nurses priority is to assess the patient for which ability?

1. Ability to administer eyedrops postprocedure

2. Ability to read discharge instructions

3. Ability to drive

4. Ability to ambulate safely

Correct Answer: 1

Rationale 1: The nurse assesses for factors that may interfere with the patients ability to provide self-care postoperatively. A family member should be included in the teaching as well.

Rationale 2: Being able to read discharge instructions is the second most important discharge assessment.

Rationale 3: Depth perception may be temporarily impaired after cataract surgery, so the patient should not drive.

Rationale 4: Safe ambulation is important but does not have the highest priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-5

Question 11

Type: MCMA

Which instructions would be appropriate for the nurse to give a patient with acute viral conjunctivitis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. You should wash your hands before cleansing the eye and using eyedrops.

2. You can soak your lids with warm saline to soften crusts and exudates.

3. You should not share towels or makeup with anyone else.

4. Do not return to work for at least 2 weeks.

5. You can use warm compresses to relieve eye discomfort.

Correct Answer: 1,2,3

Rationale 1: Hand hygiene will minimize cross-contamination and the risk of bringing other organisms to an already infected eye. Hand hygiene should be encouraged at all times, but especially in the presence of infection.

Rationale 2: Soaking the lids with sterile saline softens the crusts from exudates.

Rationale 3: The patient with conjunctivitis should not share supplies such as towels and makeup to avoid possible cross-contamination from person to person.

Rationale 4: The patient should not return to school or work if in the active stages for at least 4 days, and possibly a week to 10 days, owing to the severity and epidemic nature of viral conjunctivitis.

Rationale 5: Cold compresses for eye comfort may also help shorten the healing time and the course of the disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-2

Question 12

Type: MCSA

The nurse is reviewing discharge orders in preparation for teaching patients diagnosed with open-angle glaucoma. Which order would the nurse question?

1. Timolol (Timoptic), a beta-adrenergic blocker, for a 60-year-old with congestive heart failure (CHF)

2. Dorzolamide (Trusopt), a carbonic anhydrase inhibitor, for a patient with asthma and chronic obstructive pulmonary disease (COPD)

3. Brinzolamide (Azopt) for a 20-year-old male

4. Brimonidine (Alphagan), an adrenergic agonist, for a healthy 40-year-old on no other drugs

Correct Answer: 1

Rationale 1: Timolol (Timoptic) is a selected beta-adrenergic blocker that reduces intraocular pressure. It is contraindicated for patients with COPD, asthma, sinus bradycardia, and overt cardiovascular failure.

Rationale 2: Dorzolamide (Trusopt) lowers intraocular pressure and is often an adjunctive therapy that removes fluids through kidney filtration. It is a carbonic anhydrase inhibitor that is contraindicated in renal disease, and allergy to sulfa. This order is appropriate for this patient.

Rationale 3: Brinzolamide (Azopt) is a carbonic anhydrase inhibitor used to remove fluids through kidney filtration. A healthy 20-year-old would not have contraindications unless he is allergic to sulfa drugs.

Rationale 4: Brimonidine (Alphagan) dilates the pupil and reduces the production of aqueous humor in patients with open-angled glaucoma. This drug is appropriate for a patient who is not on clonidine or monoamine oxidase inhibitor therapy, such as this healthy 40-year-old.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-5

Question 13

Type: MCMA

The nurse is teaching a community education class on the prevention of eye injuries and caring for someone with an eye injury. What should be included in this presentation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Eye protection devices should be worn when participating in high-risk sports or occupations.

2. Most eye injuries are self-limited and do not require medical intervention.

3. Immediately flush the eye with copious amounts of water if a chemical splash occurs.

4. Loose, visible objects can be removed using a clean, moistened cotton-tipped swab.

5. If an object appears to penetrate the eye, gently remove it using sterile gauze and seek medical attention.

Correct Answer: 1,3,4

Rationale 1: Teaching related to eye injuries focuses on prevention and first-aid measures. Eye protection devices should be worn when participating in high-risk sports or occupations.

Rationale 2: Eye injuries can be serious and can cause loss of vision. Medical treatment should be obtained for all but minor injuries.

Rationale 3: Chemical burns to the eye require immediate washing of the eye for 1525 minutes.

Rationale 4: Minor foreign bodies that are loose in the eye can be carefully removed.

Rationale 5: An object that has penetrated the eye should be stabilized and left in the eye. Emergency medical treatment is essential.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-4

Question 14

Type: MCSA

A nurse is teaching a diabetic education class. One of the patients asks, What can I do to prevent going blind due to my diabetes? What is the best response by the nurse?

1. The risk of developing blindness is related to how long youve had diabetes, and how well your blood sugar and hypertension are controlled.

2. Diabetic retinopathy is caused by changes in the small blood vessels of the eye.

3. This is only a problem with type 2 diabetes, so you wont have this problem.

4. Laser photocoagulation surgery will treat any problems that develop and cure the diabetic retinopathy.

Correct Answer: 1

Rationale 1: The risk of developing diabetic retinopathy is related to the duration of the diabetes and the degree of glycemic control. Hypertension is also a risk factor.

Rationale 2: Although correct, this statement does not answer the patients question.

Rationale 3: Diabetic retinopathy is seen in both type 1 and type 2 diabetes.

Rationale 4: Laser photocoagulation is used to treat both forms of diabetic retinopathy, but it does not cure the disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-1

Question 15

Type: MCMA

The nurse is performing the corneal light reflex as part of an eye assessment. Which actions are necessary?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Shine a penlight into the patients eyes.

2. Observe the location of a light reflection in the patients pupils.

3. Touch the cornea lightly with a cotton wisp.

4. Observe for blinking.

5. Look for a whitening of the red reflex.

Correct Answer: 1,2

Rationale 1: The nurse shines a light source into the patients eyes.

Rationale 2: The nurse observes where a light reflects in the pupils. The light should strike both eyes in approximately the same place.

Rationale 3: Corneal light reflex does not include touching the eye.

Rationale 4: Blinking is not considered when eliciting corneal light reflex.

Rationale 5: Whitening of the red reflex is observed with a positive Bruckner test.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-2

Question 16

Type: MCSA

A patient reports having difficulty discriminating colors after being prescribed hydroxychloroquine (Plaquenil). What information should the nurse provide?

1. Keratometry can be done to diagnose color blindness.

2. The Ishihara test is simple and can reveal color blindness.

3. Invasive testing will be required to assess cones and rods.

4. A picture of the ocular fundus will be necessary to make this diagnosis.

Correct Answer: 2

Rationale 1: Keratometry detects astigmatism, not color blindness.

Rationale 2: The Ishihara test uses color plates that the patient views. Color blindness can be diagnosed with this test.

Rationale 3: Invasive testing is not necessary to diagnose color blindness.

Rationale 4: It is not necessary to take a picture of the ocular fundus for this diagnosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-4

Question 17

Type: MCMA

The nurse providing community education would discuss which techniques to reduce the risk of cataract development?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Smoking cessation

2. Wearing sunglasses

3. Well-balanced diet

4. Maintaining a healthy weight

5. Avoidance of alcohol

Correct Answer: 1,2,3

Rationale 1: Smoking is a risk factor for the development of cataracts.

Rationale 2: Exposure to ultraviolet light increases the risk of cataracts.

Rationale 3: A poor diet is a risk factor for the development of cataracts.

Rationale 4: Obesity is not a risk factor for cataract development.

Rationale 5: Alcohol intake is not associated with cataract development.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-1

Question 18

Type: MCMA

A patient has just returned from surgery for removal of a cataract. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Position the patient with the head of the bed up at 30 degrees.

2. Have the patient lie on the affected side.

3. Assess the operative eye for drainage.

4. Keep the eye patch in place.

5. Monitor the patients pain level.

Correct Answer: 1,3,4,5

Rationale 1: The patient should recline at a 30-degree angle.

Rationale 2: The patient should lie on the unaffected side.

Rationale 3: The nurse will monitor for drainage from the affected eye.

Rationale 4: The patients eye patch should be kept in place.

Rationale 5: A sudden onset of pain may be related to a ruptured vessel.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-2

Question 19

Type: MCSA

The nurse is assessing a patient who had cataract surgery several weeks ago. Which patient statement would alert the nurse that the most common complication of cataract surgery is occurring in this patient?

1. My eye itches at night.

2. My vision has not been as clear as I thought it would be.

3. I think my cataract is growing back.

4. I have pus in the corner of my eye.

Correct Answer: 3

Rationale 1: Itching is not the most common complication of cataract surgery.

Rationale 2: Numerous complications can result in the vision not being clear. These are not the most common complications.

Rationale 3: Posterior capsular opacity is the most common complication of cataract surgery and is evidenced by increasingly blurry vision. The patient may describe this change as the cataract growing back.

Rationale 4: Infection may occur, resulting in pus formation, but this is not the most common complication of cataract surgery.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-2

Question 20

Type: FIB

A patient is being discharged after cataract surgery. The nurse evaluates that the patient understands discharge instructions when the patient says, I should not pick up anything that weighs more than _______ pounds.

Standard Text:

Correct Answer: 15

Rationale : To avoid increasing intraocular pressure, the patient should not pick up anything that weighs more than 15 pounds.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 64-5

Question 21

Type: MCMA

The nurse has provided discharge instructions to a patient who had cataract surgery. The nurse is satisfied that the patient understands these instructions when the patient makes which statements?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I will ask my wife to tie my shoes for a few days.

2. I will wear my eye shield all the time.

3. I should expect to see bright flashes of light as my eye heals.

4. I will avoid reading at least until my follow-up appointment next week.

5. I will sleep on my back or on my nonoperative side.

Correct Answer: 1,4,5

Rationale 1: The patient should avoid activities that require bending over at the waist, such as tying the shoes.

Rationale 2: The patient should wear the eye shield during sleep but should wear glasses when awake so that the operative eye is being used.

Rationale 3: Bright flashes of light are not normal and should be reported.

Rationale 4: The patient should avoid reading for some time to minimize strain on the healing eye.

Rationale 5: The patient should not sleep on the operative side.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 64-5

Question 22

Type: MCMA

A 63-year-old African woman is seen in the clinic for an eye examination. The woman has diabetes, smokes a pack of cigarettes a day, and drinks a pot of coffee each day. The nurse identifies which findings from this history as increasing the patients risk of glaucoma?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ethnic origin

2. Age

3. Caffeine intake

4. Comorbidity

5. Smoking

Correct Answer: 1,2,4,5

Rationale 1: People who are of African, African American, and African Caribbean ethnic background have a higher risk of developing glaucoma.

Rationale 2: The risk of developing glaucoma increases with age.

Rationale 3: There is no identified connection between caffeine intake and the development of glaucoma.

Rationale 4: The fact that the patient has diabetes increases the risk of glaucoma.

Rationale 5: Smoking increases the risk for the development of glaucoma.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 64-1

Question 23

Type: MCSA

A patient with a corneal abrasion is being discharged after treatment with fluorescein and proparacaine drops. Looking in the mirror, the patient says, My eye is yellow! What happened? How should the nurse respond?

1. Unfortunately, corneal abrasion treatment can cause discoloration of the eye for several weeks.

2. The color helps us see the abrasion and will be washed away by your normal tears.

3. I have not seen this reaction before. I will contact the health care provider.

4. When you get home, put a hot compress on the eye. If the color doesnt clear in an hour, call us back.

Correct Answer: 2

Rationale 1: The discoloration should not last several weeks.

Rationale 2: Drops are used to numb the eye and help identify the presence, size, and location of the corneal abrasion. They leave a yellow-green discoloration in the eye, on the lashes, and on surrounding tissue that will clear with tears.

Rationale 3: The nurse should be prepared to answer this question and provide discharge instruction.

Rationale 4: There is no need for a hot compress, which is likely contraindicated for the injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-3

Question 24

Type: MCSA

A patient is prescribed ranibuizumag (Lucentisz) as treatment for age-related macular degeneration. The nurse would assess this patient for which expected adverse reaction?

1. Sudden increase in urine output

2. Petechiae across the patients chest

3. Thickened bronchial secretions

4. Photophobia

Correct Answer: 2

Rationale 1: The patient is at greater risk of fluid overload, which would manifest as decreased urine output.

Rationale 2: The patient should be monitored for abnormal bleeding.

Rationale 3: Thickening of bronchial secretions is not an adverse effect of this drug.

Rationale 4: Photophobia is not an expected effect of this medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-2

Question 25

Type: MCMA

A patient diagnosed with glaucoma says, I cant believe this is happening to me and that I cant change it. Everything I do requires that I see well. Which nursing questions will address the issue reflected in this statement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. What time is good for you to return to the clinic tomorrow for a recheck?

2. Did you bring someone to drive you home?

3. Which pharmacy location do you want me to call with your new prescription?

4. Is someone staying with you until your vision is clearer?

5. Do you want black sunglasses or red ones?

Correct Answer: 1,3,5

Rationale 1: This patient is expressing a sense of powerlessness. Letting the patient set the time for the next appointment restores some power.

Rationale 2: Requiring someone to drive the patient around may increase this patients sense of powerlessness.

Rationale 3: This patient is expressing a sense of powerlessness. Allowing the patient to determine treatment options, even as simple as choosing the location of the pharmacy, may help to restore some sense of power.

Rationale 4: The necessity of having someone baby-sit the patient, while necessary, will further diminish the patients sense of control and power.

Rationale 5: Allowing simple choices helps to establish a feeling of control over ones own care, which increases ones sense of power.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-3

Question 26

Type: MCMA

Glaucoma is the second leading cause of blindness in the United States. The nurse providing health promotion materials should focus information on which issues contributing to that statistic?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Delayed recognition of glaucoma

2. Noncompliance in using eyedrops once diagnosed

3. Lack of understanding of the seriousness of the disorder

4. Difficulty achieving normal pressure readings once glaucoma is established

5. Reluctance to seek treatment due to social stigma of the disease

Correct Answer: 1,2,3

Rationale 1: Glaucoma is often silent and requires professional assessment for diagnosis. Many people do not realize they have glaucoma.

Rationale 2: People diagnosed with glaucoma sometimes do not use eyedrops correctly or consistently once symptoms of glaucoma are controlled.

Rationale 3: Many people do not understand how serious glaucoma is and that it can result in blindness.

Rationale 4: Glaucoma is easily treated once diagnosed.

Rationale 5: There is no social stigma associated with glaucoma.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-1

Question 27

Type: MCMA

The nurse is teaching a patient about dietary considerations associated with the diagnosis of glaucoma. Which foods should the nurse teach the patient to avoid?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Citrus fruits

2. Cheese

3. White dinner rolls

4. Gas-producing foods such as beans and broccoli

5. Beef

Correct Answer: 2,3,5

Rationale 1: The patient should eat a variety of fruits and vegetables. Citrus fruits are not eliminated from this diet.

Rationale 2: Cheese can be constipating. The patient with glaucoma should avoid becoming constipated as straining at stool increases intraocular pressure.

Rationale 3: The patient should avoid products made with white flour.

Rationale 4: The patient should increase vegetables such as beans and broccoli. There is no need to avoid gas-producing foods.

Rationale 5: Beef can be constipating and should be reduced in the diet of a patient with glaucoma.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 64-4

Question 28

Type: FIB

The nurse is admitting a patient for laser photocoagulation treatment of diabetic retinopathy. The nurse would immediately contact the health care provider if the patients diastolic blood pressure is above _______ mmHg.

Standard Text:

Correct Answer: 100

Rationale : A diastolic blood pressure above 100 mmHg or blood sugar over 300 mg/dL can require delay of the planned treatment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 64-2

Question 29

Type: MCMA

A patient with severe diabetic retinopathy is nearly blind despite years of various treatments. Which patient statements would the nurse evaluate as indicating this patient is coping with the disability?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I went to a luncheon at church this week.

2. My husband put some Velcro on my washing machine so I could tell which setting to use.

3. I dont get out of doors very often, so it is fun to come to the doctor.

4. My daughters found a new low-carbohydrate recipe to try for my birthday cake this year.

5. I would so love to really be able to see my new grandsons face.

Correct Answer: 1,2,4

Rationale 1: Resuming social interactions is a positive sign of coping.

Leave a Reply