A nurse is planning care for a client 1 day postoperative following a detached retinal repair.
Which of the following instructions should the nurse include?

Allow the client to ambulate.

Remove the eye patch during the day.

Encourage coughing and deep-breathing.

Avoid reading and writing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.

Choice B rationale

Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.

Choice C rationale

Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.

Choice D rationale

Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.

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Correct Answer is C

Explanation

Choice A rationale

Informing the client that she will need to bring the tick for testing is not necessary. While having the tick can help identify the species and potential risk, it is not required for testing for Lyme disease. The diagnosis can be made based on clinical symptoms and blood tests.

Choice B rationale

Informing the client that the tick is needed to perform a test is incorrect. The presence of the tick is not required for testing for Lyme disease. Blood tests can detect antibodies to the bacteria that cause Lyme disease, even if the tick is not available.

Choice C rationale

Referring the client for a blood test immediately is the appropriate action. Early testing can help diagnose Lyme disease and initiate treatment promptly. Blood tests can detect antibodies to Borrelia burgdorferi, the bacteria that cause Lyme disease, and help confirm the diagnosis.

Choice D rationale

Asking the client about the size and color of the tick is not the most appropriate action. While this information can provide some context, it does not directly contribute to the diagnosis of Lyme disease. The priority is to refer the client for a blood test to confirm the presence of the infection.

A. The medication is to be used for approximately 10 days followed by a gradual tapering off. B. The medication should be applied on a regular schedule for the rest of the client’s life. C. The medication will be used until the client’s intraocular pressure returns to normal. D. The medication is to be applied when the client is experiencing eye pain.

Correct Answer is B

Explanation

Choice A rationale

Timolol is a beta-blocker used to reduce intraocular pressure in patients with open-angle glaucoma. It is not intended for short-term use or gradual tapering off. The medication must be used consistently to maintain its therapeutic effect.

Choice B rationale

Timolol should be applied on a regular schedule for the rest of the client’s life to effectively manage intraocular pressure and prevent further damage to the optic nerve.

Choice C rationale

Timolol does not cure glaucoma or normalize intraocular pressure permanently. Continuous use is necessary to control the condition.

Choice D rationale

Timolol is not used as a pain reliever. It is specifically prescribed to manage intraocular pressure in glaucoma patients.

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A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include?

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A nurse is planning care for a client 1 day postoperative following a detached retinal repair.
Which of the following instructions should the nurse include?