A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?
Rest in bed for at least 2 days.
Deep breathe and cough four times a day.
After two days, a creamy discharge is normal.
Keep your head up and straight.
The Correct Answer is D
Choice A reason: Resting in bed for at least 2 days is not necessary after cataract surgery. The client should resume normal activities as soon as possible, but avoid strenuous activities that increase intraocular pressure.
Choice B reason: Deep breathing and coughing four times a day are not related to cataract surgery. This is a technique to prevent respiratory complications after abdominal or thoracic surgery.
Choice C reason: After two days, a creamy discharge is not normal. This could indicate an infection or inflammation of the eye. The client should report any changes in vision, pain, redness, swelling, or discharge to the provider.
Choice D reason: Keeping the head up and straight is the correct instruction. This helps to prevent increased intraocular pressure and bleeding in the eye. The client should also avoid rubbing or touching the eye, wearing sunglasses to protect from bright light, and using prescribed eye drops as directed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because drawing with crayons may be too childish or frustrating for a client with moderate Alzheimer's. Crayons may also pose a choking hazard or cause messes. The nurse should provide activities that are suitable for the client's cognitive and functional level, as well as their interests and preferences.
Choice B Reason: This is incorrect because dangling ribbons or a mobile may be too stimulating or confusing for a client with moderate Alzheimer's. These items may also trigger agitation or wandering behaviors. The nurse should provide activities that are calming and familiar for the client.
Choice C Reason: This is correct because listening to music, watching TV, or videos can be enjoyable and beneficial for a client with moderate Alzheimer's. Music can evoke memories, emotions, and positive responses. TV or videos can provide entertainment, education, and socialization. The nurse should choose music, TV shows, or videos that are appropriate and meaningful for the client.
Choice D Reason: This is incorrect because board games may be too complex or challenging for a client with moderate Alzheimer's. Board games may require memory, concentration, logic, or strategy skills that the client may have lost. The nurse should provide activities that are simple and easy for the client to follow.
Correct Answer is D
Explanation
Choice A Reason: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves.
Choice B Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases.
Choice C Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection.
Choice D Reason: This is the correct answer because cytomegalovirus is one of the common infections that can trigger Guillain-Barre syndrome. It can cause inflammation and damage to the myelin sheath that covers the nerves.
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