A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
"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."
"The bright light in this room is really bothering me."
"I need something for the pain in my eye. I can't stand it."
The Correct Answer is D
Choice A reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have reduced vision and an increased risk of falling with a patch on one eye after cataract surgery. The nurse should reassure the client, provide assistance with mobility, and educate the client on safety measures.
Choice B reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have some itching and discomfort in the eye after cataract surgery. The nurse should commend the client for not rubbing the eye, as this can cause infection or damage to the surgical site. The nurse should also administer anti-inflammatory eye drops as prescribed and instruct the client on how to apply them.
Choice C reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have increased sensitivity to light in the eye after cataract surgery. The nurse should dim the lights in the room, provide sunglasses or a shield for the eye, and educate the client on how to protect the eye from bright light.
Choice D reason: This is the correct answer because this comment requires reporting to the client's provider. Severe pain in the eye after cataract surgery can indicate a complication such as infection, inflammation, bleeding, or increased intraocular pressure. The nurse should assess the eye for signs of redness, swelling, discharge, or bleeding, and report the findings and the pain level to the provider. The nurse should also administer analgesics as prescribed and monitor the pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because this describes a stupor, which is a state of near-unconsciousness or reduced responsiveness. A stuporous client shows minimal movement and verbal responses and requires extreme vigorous stimulation such as painful stimuli to awaken briefly.
Choice B reason: This is incorrect because this describes obtundation, which is a state of reduced alertness or awareness. An obtunded client is extremely drowsy and minimally responsive and requires vigorous stimulation such as shaking or shouting to wake.
Choice C reason: This is incorrect because this describes lethargy, which is a state of decreased energy or activity. A lethargic client is alert and oriented x3 (to person, place, and time), but sluggish and drowsy, and wakes to voice or gentle shaking.
Choice D reason: This is incorrect because this describes a coma, which is a state of deep unconsciousness or unresponsiveness. A comatose client does not respond to verbal stimuli or speak and shows abnormal posturing in response to pain, such as decorticate (flexion of arms and extension of legs) or decerebrate (extension of arms and legs).
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because phototherapy is not a recommended therapy for contact dermatitis. Phototherapy involves exposing the skin to artificial light sources that emit specific wavelengths of light that can have anti-inflammatory or immunomodulatory effects. Phototherapy can be used for some skin conditions, such as psoriasis or eczema, but not for contact dermatitis.
Choice B Reason: This is incorrect because antibiotics are not a recommended therapy for contact dermatitis. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Contact dermatitis is not an infection, but an allergic or irritant reaction to a substance that comes in contact with the skin. Antibiotics have no effect on contact dermatitis and may cause adverse effects or resistance.
Choice C Reason: This is incorrect because UV light is not a recommended therapy for contact dermatitis. UV light refers to ultraviolet radiation from sunlight or artificial sources that can damage DNA and cause skin cancer or aging. UV light can also worsen contact dermatitis by increasing inflammation and sensitivity to allergens or irritants.
Choice D Reason: This is correct because avoidance is the best therapy for contact dermatitis. Avoidance means identifying and avoiding the substance that causes the skin reaction. This can prevent further exposure and allow the skin to heal. The nurse can help the client by providing education on how to read labels, use protective clothing or gloves, or substitute safer products.
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