A nurse is performing a tonometry test on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23 mm Hg. What should the nurse's initial action be?

Note the time of day the test was done.

Apply normal saline drops.

Instruct the client to sleep with the head of the bed flat.

Contact the primary health care provider.

Answer and Explanation

The Correct Answer is D

A. While noting the time of day is important for documentation, it does not address the immediate concern of elevated intraocular pressure (IOP).
B. Applying normal saline drops is not indicated in the immediate management of elevated IOP in glaucoma; it does not directly affect IOP levels.
C. Instructing the client to sleep with the head of the bed flat is not advisable, as elevated head positions may help decrease IOP.
D. An IOP of 23 mm Hg is above the normal range (10-21 mm Hg) and indicates potential glaucoma. Therefore, contacting the primary health care provider for further evaluation and treatment is the most appropriate initial action.

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Correct Answer is D

Explanation

A. Hypotension is not typically associated with adrenal cortex hyperfunction; in fact, patients may experience hypertension due to excess cortisol and aldosterone.
B. Dehydration is more common with adrenal insufficiency than hyperfunction, as excess hormone production often leads to fluid retention.
C. Hyponatremia is generally not a concern with adrenal cortex hyperfunction; clients may experience hypernatremia instead due to fluid retention.
D. Hypokalemia is a significant risk in clients with adrenal cortex hyperfunction, especially due to the effects of excessive aldosterone, which promotes sodium retention and potassium excretion.

A. "The pool water has chlorine that is killing all of the good bacteria." B. "The pool water is entering your Eustachian tubes." C. "The pool water has microorganisms that are entering your ears." D. "The pool water is drying out your ears, causing skin breakdown."

Correct Answer is C

Explanation

A. While chlorine can kill some bacteria, it does not prevent all microbial growth and does not directly explain ear infections.
B. Pool water entering the Eustachian tubes is unlikely; infections are more commonly related to pathogens in the water.
C. The best response addresses the presence of microorganisms in pool water that can enter the ear and potentially lead to infections, such as swimmer's ear (otitis externa).
D. Pool water is not typically associated with drying out the ears; rather, it can lead to excess moisture, which can promote bacterial growth.

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A nurse is performing a tonometry test on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23 mm Hg. What should the nurse's initial action be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with Adrenal Cortex Hyperfunction. The nurse is aware that the client is at risk for which of the following?

Correct Answer is D

Explanation

A client who swims several times a week asks the nurse, "Why are ears prone to frequent infection?" What is the nurse's best response?

Correct Answer is C

Explanation

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