The caregiver of an elderly client asks the nurse what can be done about the chronic bilateral inflammation of the eyelid margins that keeps recurring. Which of the following is the information that the nurse will provide?
Instill eye drops in both eyes every hour around the clock
Use sterile gloves when assisting with activities of daily living
Use baby shampoo on the eyelid margins
Use a salt scrub inside the eyelid
The Correct Answer is C
Choice A Reason: This choice is incorrect. Instilling eye drops in both eyes every hour around the clock is not an information that the nurse will provide, as it is not a recommended treatment for chronic bilateral inflammation of the eyelid margins. This condition is also known as blepharitis, which is a common and chronic disorder that causes redness, itching, burning, and crusting of the eyelids. Eye drops may be used to relieve symptoms, but not every hour or without a prescription.
Choice B Reason: This choice is incorrect. Using sterile gloves when assisting with activities of daily living is not an information that the nurse will provide, as it is not a necessary precaution for chronic bilateral inflammation of the eyelid margins. Blepharitis is not contagious or infectious, but rather caused by an overgrowth of bacteria or mites on the eyelids, or by an underlying skin condition such as seborrheic dermatitis or rosacea.
Choice C Reason: This is the correct choice. Using baby shampoo on the eyelid margins is an information that the nurse will provide, as it is a simple and effective way to clean and soothe the eyelids. Baby shampoo is gentle and non-irritating, and can help remove excess oil, debris, and scales from the eyelids. The nurse will instruct the caregiver to dilute a few drops of baby shampoo with warm water, apply it to a cotton ball or washcloth, and gently rub it along the eyelid margins. The nurse will also advise to rinse well with water and pat dry with a clean towel.
Choice D Reason: This choice is incorrect. Using a salt scrub inside the eyelid is not an information that the nurse will provide, as it is a harmful and painful method that can damage and irritate the eye. Salt scrub is abrasive and drying, and can cause corneal abrasion, infection, or inflammation. The nurse will warn the caregiver to avoid using any harsh or unapproved products on or near the eye.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
Choice B reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
Choice C reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
Choice D reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.
Correct Answer is D
Explanation
Choice A Reason: The burned area is yellow in color with severe edema is not a finding of a deep partial-thickness burn, but a superficial partial-thickness burn. A superficial partial-thickness burn involves the epidermis and the upper layer of the dermis, causing pain, redness, swelling, and blistering.
Choice B Reason: The burned area is black in color and pain is absent is not a finding of a deep partial-thickness burn, but a full-thickness burn. A full-thickness burn involves the epidermis, dermis, and underlying tissues, causing necrosis, charred skin, and loss of sensation.
Choice C Reason:This description aligns with a superficial partial-thickness (first-degree or mild second-degree) burn rather than a deep partial-thickness burn. Superficial partial-thickness burns involve the epidermis and the upper portion of the dermis. These burns appear pink or red, often accompanied by moisture and blister formation due to fluid leakage from damaged capillaries. They are painful because nerve endings remain intact. Healing occurs within 10 to 21 days without significant scarring.
Choice D Reason:Deep partial-thickness burns extend deeper into the dermis, damaging a larger portion of skin structures, including sweat glands and hair follicles. These burns typically appear red or white and may have a soft eschar (dead tissue), which differentiates them from more superficial burns that do not develop eschar. Unlike full-thickness burns, nerve endings remain partially intact, so the patient may still experience some pain. These burns take more than 21 days to heal and often require skin grafting to prevent complications such as contractures or hypertrophic scarring.
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