A client with open-angle glaucoma is using pilocarpine ophthalmic solution, a miotic agent. Which action should the nurse at the eye clinic include in evaluating the effectiveness of the medication?
Use Snellen chart to assess visual acuity.
Check amount of drainage from each eye.
Palpate eyelids for decreased swelling.
Review eye pressure measurements.
The Correct Answer is D
Choice A reason: Using a Snellen chart to assess visual acuity is not a direct measure of the effectiveness of pilocarpine, which is used to lower intraocular pressure by constricting the pupil and increasing aqueous humor outflow. Visual acuity may be affected by other factors, such as refractive errors, cataracts, or macular degeneration.
Choice B reason: Checking the amount of drainage from each eye is not a relevant action for evaluating the effectiveness of pilocarpine, which does not affect tear production or drainage. Excessive or abnormal eye drainage may indicate an infection, allergy, or injury.
Choice C reason: Palpating the eyelids for decreased swelling is not a useful action for evaluating the effectiveness of pilocarpine, which does not cause or reduce eyelid swelling. Eyelid swelling may be caused by inflammation, infection, allergy, or trauma.
Choice D reason: Reviewing eye pressure measurements is the correct action for evaluating the effectiveness of pilocarpine, which is used to lower intraocular pressure in patients with open-angle glaucoma. High intraocular pressure can damage the optic nerve and cause vision loss. Pilocarpine reduces intraocular pressure by constricting the pupil and increasing aqueous humor outflow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Flatulence and nausea are common side effects of azithromycin, which is a macrolide antibiotic that inhibits bacterial protein synthesis. These symptoms are usually mild and transient, and do not require reporting to the health care provider unless they are severe or persistent.
Choice B reason: Urinary frequency is not a relevant symptom of azithromycin, which does not affect urinary function or bladder control. Urinary frequency may be caused by other factors, such as infection, diabetes, or pregnancy.
Choice C reason: Yellow sclera is a serious symptom of azithromycin, which indicates liver damage or jaundice. Azithromycin can cause hepatotoxicity, which is a rare but potentially fatal adverse reaction. Yellow sclera should be reported to the health care provider immediately, as it may require discontinuation of the medication and liver function tests.
Choice D reason: Headache is a common side effect of azithromycin, which is a macrolide antibiotic that inhibits bacterial protein synthesis. This symptom is usually mild and transient, and does not require reporting to the health care provider unless it is severe or persistent.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason:
Seizures are not a common side effect of morphine, and they are unlikely to contribute to this client's fall risk. Seizures can occur in rare cases of morphine overdose, hypersensitivity, or withdrawal, but they are not expected in a client who is receiving a continuous and monitored dose of morphine. Therefore, choice A is incorrect.
Choice B reason:
Nausea is a common side effect of morphine, and it can contribute to this client's fall risk. Nausea can cause the client to feel dizzy, weak, or unsteady, and it can also impair the client's appetite and hydration status. Nausea can also trigger vomiting, which can increase the risk of aspiration or dehydration. Therefore, choice B is correct.
Choice C reason:
Orthostatic hypotension is a common side effect of morphine, and it can contribute to this client's fall risk. Orthostatic hypotension is a sudden drop in blood pressure that occurs when the client changes position from lying to sitting or standing. Orthostatic hypotension can cause the client to feel faint, dizzy, or lightheaded, and it can also increase the risk of syncope (loss of consciousness) or cardiac arrhythmias. Therefore, choice C is correct.
Choice D reason:
Sedation is a common side effect of morphine, and it can contribute to this client's fall risk. Sedation can cause the client to feel sleepy, drowsy, or confused, and it can also impair the client's alertness and coordination. Sedation can also reduce the client's ability to respond to stimuli or alarms, and it can increase the risk of respiratory depression or coma. Therefore, choice D is correct.
Choice E reason:
Euphoria is a common side effect of morphine, and it can contribute to this client's fall risk. Euphoria is a feeling of intense happiness or well-being that is induced by the activation of opioid receptors in the brain. Euphoria can cause the client to feel overconfident, impulsive, or reckless, and it can also impair the client's judgment and perception of reality. Euphoria can also increase the risk of psychological dependence or addiction. Therefore, choice E is correct.
Choice F reason:
Itching is a common side effect of morphine, and it can contribute to this client's fall risk. Itching is caused by the release of histamine from mast cells in response to the stimulation of opioid receptors in the skin. Itching can cause the client to scratch excessively, which can damage the skin and increase the risk of infection. Itching can also distract the client from other sensations or warnings, and it can reduce the client's comfort and quality of life. Therefore, choice F is correct.
Choice G reason:
Urinary retention is a common side effect of morphine, and it can contribute to this client's fall risk. Urinary retention is the inability to empty the bladder completely or voluntarily due to the inhibition of bladder contraction by opioid receptors in the urinary tract. Urinary retention can cause the client to feel pain, discomfort, or urgency in the lower abdomen, and it can also increase the risk of urinary tract infection or kidney damage. Urinary retention can also prompt the client to attempt to get out of bed without assistance or supervision, which can increase the risk of falling. Therefore, choice G is correct.
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