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 encouraging coughing and deep breathing can increase intracranial pressure (ICP), which is the pressure inside
the skull that can affect brain function. Coughing and deep breathing can increase blood flow and oxygen demand to the brain, which can worsen cerebral edema. The nurse should suction the patient as needed and maintain a patent airway.
Choice B Reason: This is incorrect because positioning the patient with knees and hips flexed can increase ICP by reducing venous drainage from the head. The nurse should position the patient with neck and body in alignment and avoid extreme flexion or extension of any joints.
Choice C Reason: This is incorrect because performing nursing interventions once an hour can disturb the patient's sleep and increase ICP by stimulating brain activity. The nurse should cluster nursing interventions and provide quiet and dark environment to promote rest and reduce stress.
Choice D Reason: This is correct because keeping the head of the bed elevated to 30 degrees can decrease ICP by facilitating venous drainage from the head and reducing cerebral blood volume. The nurse should monitor the patient's blood pressure and pulse to ensure adequate cerebral perfusion.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because atrial fibrillation is the risk factor that puts the client at
the highest risk for embolic stroke. Atrial fibrillation is an irregular and rapid heart rate that causes poor blood flow and blood pooling in the heart chambers. This can lead to the formation of blood clots that can travel to the brain and block an artery, causing an embolic stroke.
Choice B reason: This is incorrect because hypertension is not the risk factor that puts the client at
the highest risk for embolic stroke. Hypertension is high blood pressure that puts stress on the blood vessels and increases the risk of bleeding or rupture. This can lead to a hemorrhagic stroke, but not an embolic stroke.
Choice C reason: This is incorrect because diabetes is not the risk factor that puts the client at
the highest risk for embolic stroke. Diabetes is a condition that causes high blood sugar levels and damages the blood vessels and nerves. This can lead to poor circulation and increased risk of infection and ulcers, but not an embolic stroke.
Choice D reason: This is incorrect because alcohol abuse is not the risk factor that puts the client at
the highest risk for embolic stroke. Alcohol abuse is excessive consumption of alcohol that affects liver function and blood clotting factors. This can lead to liver disease and bleeding disorders, but not an embolic stroke.
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