A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?
"Take a stool softener daily."
"You can lift objects that weigh 15 pounds."
"Avoid reading for 3 days following surgery."
"Pick up items by bending at the waist."
The Correct Answer is A
Rationale:
A. "Take a stool softener daily.": Preventing straining during bowel movements is critical after retinal surgery because increased intraocular pressure from straining can disrupt the surgical repair. Stool softeners help maintain soft stools and reduce the risk of increased eye pressure.
B. "You can lift objects that weigh 15 pounds.": Clients should avoid heavy lifting after retinal surgery to prevent increased intraocular pressure. The amount of weight considered safe is minimal, and lifting anything heavier can compromise the surgical site.
C. "Avoid reading for 3 days following surgery.": Light visual activities like reading are usually permitted after surgery, depending on provider instructions. Complete restriction is unnecessary, though clients should avoid activities that increase eye strain or involve prolonged downward gaze.
D. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure, which can compromise the retina. Clients should be instructed to bend at the knees and keep the head upright when picking up objects to protect the surgical repair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Encourage cultural practices to be incorporated into their care: Respecting and incorporating a Muslim client’s cultural and religious practices promotes culturally competent and patient-centered care. This approach fosters trust, comfort, and cooperation between the client and healthcare team.
B. Incorporate hot and cold practices into the client's care: Hot and cold theory is typically associated with Hispanic, Asian, and Middle Eastern folk medicine traditions, but not all Muslim clients follow this practice. Care should be based on the client’s individual beliefs.
C. Acknowledge that the client may be cared for by a male provider: Many Muslim women prefer to be cared for by female providers due to religious and cultural values of modesty. The nurse should make reasonable efforts to accommodate this preference whenever possible.
D. Have the client remove any face coverings to obtain their history: Muslim women who wear a niqab or hijab may choose to keep their face covered for modesty. The nurse should not insist on removal unless necessary for identification or assessment, and even then, it should be done privately with sensitivity to religious beliefs.
Correct Answer is C
Explanation
Rationale:
A. "I need to be discharged now due to household responsibilities.": This statement reflects denial of the seriousness of preeclampsia and poor coping, as the client is prioritizing home duties over health. Clients with preeclampsia require rest, monitoring, and adherence to medical advice to prevent complications such as eclampsia or HELLP syndrome.
B. "I am so bored of being on restricted activity.": Expressing boredom is a normal emotional reaction but does not indicate effective coping. It shows frustration with activity limitations rather than acceptance and constructive adaptation to the treatment plan.
C. "I am using a notebook to record questions for my providers.": Keeping a notebook demonstrates proactive engagement and self-management. This behavior reflects effective coping, as the client is taking responsibility for understanding their condition and participating in care decisions to promote safety and adherence.
D. "I don't want any visitors while I'm here.": Avoiding social support may indicate withdrawal or emotional distress. Isolation can hinder coping and increase anxiety, whereas maintaining open communication and support networks usually improves adjustment to the condition.
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