A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Initiate a referral for ophthalmic evaluation as soon as possible.

Advise the client to maintain normal activities, but avoid contact sports until the spots resolve

Instruct the client to rest, and report to the emergency department if eye pain develops.

Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Answer and Explanation

The Correct Answer is A

A.   The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B.   This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C.   While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D.   Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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Correct Answer is C

Explanation

A. While it's important to monitor for complications, this is not a typical initial instruction for a soft tissue injury.
B. Early range of motion exercises are generally not recommended for acute soft tissue injuries, as they can increase swelling and pain.
C. This is the correct instruction. Applying ice to the injured area helps reduce swelling and pain. It should be applied intermittently to prevent tissue damage from excessive cold.
D. Heat is typically used in the later stages of healing to promote blood flow and relaxation, but continuous heat application can be harmful in the acute phase.

A. Place pillows around the bed rails to provide padding. B. Watch the seizure activity and document the time and client movement. C. Manually ventilate the client with a bag-valve mask (BVM). D. Stop the IV fluids. E. Increase the supplemental oxygen to 10 L/minute via nasal cannula. F. Begin chest compressions.

Correct Answer is ["B","C","E"]

Explanation

A. This is important to prevent injury but is not the priority at this time.
B. This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation.
C. This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient.
D. This is not necessary at this point and may not be feasible during the emergency situation.
E. While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels.
F. Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.

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A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?

Correct Answer is C

Explanation

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

Correct Answer is ["B","C","E"]

Explanation

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