A nurse is caring for a client following cataract surgery. Which comment from the client should the nurse report to the client's health care provider IMMEDIATELY?
The bright light in this room is really bothering me
It's hard to see with a patch on one eye, I'm afraid of falling
My eye really itches but I'm trying not to rub it
I need something for the pain in my eye, I can't stand it
The Correct Answer is D
Choice A reason: Bright light sensitivity is a common side effect following cataract surgery and can be managed with appropriate measures such as wearing sunglasses. It does not necessarily indicate a complication requiring immediate reporting.
Choice B reason: Difficulty seeing with a patch on one eye and fear of falling are valid concerns, but they do not necessarily indicate an immediate complication that requires urgent reporting to the healthcare provider.
Choice C reason: Eye itching is common after cataract surgery, and the client should be advised not to rub the eye to prevent infection or damage. This comment does not indicate a severe complication that needs immediate reporting.
Choice D reason: Severe eye pain that the client cannot stand is a potential sign of a serious complication, such as increased intraocular pressure, infection, or other postoperative issues. This requires immediate attention from the healthcare provider to prevent further complications and ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots" is incorrect. Atrial fibrillation primarily causes blood to pool in the atria, not the legs.
Choice B reason: The statement "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain" accurately explains the risk of clot formation in atrial fibrillation and the importance of anticoagulant therapy to prevent strokes and other complications.
Choice C reason: The statement "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them" is incorrect. Anticoagulant therapy in atrial fibrillation is used to prevent clot formation due to the arrhythmia itself, not as a counteraction to the side effects of other medications.
Correct Answer is B
Explanation
Choice A reason: While treating the injuries is important, addressing the root cause of abuse is crucial for the client's safety. Simply treating the injuries without addressing the abuse may allow the cycle of harm to continue.
Choice B reason: Reporting the abuse is a legal and ethical responsibility for healthcare providers. Ensuring the client's safety and providing necessary interventions to stop the abuse is paramount.
Choice C reason: Calling the emergency department is not the correct response. The nurse should follow the proper protocol for reporting abuse, which involves notifying social services or other relevant authorities.
Choice D reason: Keeping the information in confidence is not appropriate when dealing with abuse cases. The nurse must act to protect the client and report the abuse to prevent further harm.
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