A nurse in the ambulatory care unit is caring for a client after cataract extraction. The client suddenly complains of severe pain in the affected eye unrelieved by pain medications. Which of the following actions should the nurse take first?
Tell the client that this is to be expected after surgery.
Place the client in a supine position.
Document the findings.
Notify the surgeon.
The Correct Answer is D
Choice A Reason: Telling the client that this is to be expected after surgery is not the first action that the nurse should take, as it may indicate a complication such as increased intraocular pressure, hemorrhage, or infection.
Choice B Reason: Placing the client in a supine position is not the first action that the nurse should take, as it may worsen the pain and increase intraocular pressure.
Choice C Reason: Documenting the findings is not the first action that the nurse should take, as it may delay the intervention and outcome.
Choice D Reason: Notifying the surgeon is the first action that the nurse should take, as it indicates that the client needs immediate evaluation and treatment to prevent vision loss or permanent damage to the eye.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Sharing personal hygiene items like razors is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, which are blood-borne infections.
Choice B Reason: Unprotected sexual activity is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other sexually transmitted infections.
Choice C Reason: Eating uncooked foods is a common way of spreading hepatitis A, as the virus can contaminate food or water that has been exposed to fecal matter from an infected person.
Choice D Reason: Getting a tattoo is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other blood-borne infections, if the equipment is not properly sterilized.
Correct Answer is D
Explanation
Choice A Reason: Parkinson's disease does not result from too low acetylcholine as a result of an autoimmune reaction, but this may be a description of myasthenia gravis, which affects the neuromuscular junction.
Choice B Reason: Parkinson's disease is not caused by the deterioration of the myelin sheath of the basal ganglia, but this may be a description of multiple sclerosis, which affects the central nervous system.
Choice C Reason: Excess dopamine and deficient acetylcholine are not the two major causes of Parkinson's disease, but they are reversed. Parkinson's disease is caused by low dopamine and high acetylcholine levels in the brain.
Choice D Reason: Parkinson's is caused by depletion of dopamine and excess of acetylcholine, as this affects the balance between these two neurotransmitters that control movement and coordination.
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