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The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

Puts the eye drops in a room with low lighting

Washes their hands before placing the eye drops

Uses the patient’s iris as a landmark for direct placement of the drop

Puts the drop from inner to outer canthus

Holds the upper eyelid open when placing the drop

Answer and Explanation

Correct Answer : B,D

b. Washes their hands before placing the eye drops

d. Puts the drop from inner to outer canthus

Explanation of Choices

Choice A Reason: Puts the Eye Drops in a Room with Low Lighting

Administering eye drops in a room with low lighting is not a recommended practice. Proper lighting is essential to ensure accurate placement of the drops and to avoid contamination or injury. Low lighting can make it difficult to see the eye and the dropper, increasing the risk of improper administration. Therefore, this action does not indicate correct performance of the skill.

Choice B Reason: Washes Their Hands Before Placing the Eye Drops

Washing hands before administering eye drops is a crucial step to prevent infection and contamination. Clean hands reduce the risk of transferring bacteria or other pathogens to the eye, which can cause infections or other complications. This action is a fundamental part of proper eye drop administration and indicates correct performance of the skill.

Choice C Reason: Uses the Patient’s Iris as a Landmark for Direct Placement of the Drop

Using the patient’s iris as a landmark for direct placement of the drop is incorrect. The proper technique involves pulling down the lower eyelid to create a small pocket (conjunctival sac) and placing the drop into this pocket. Directly aiming for the iris can cause discomfort and increase the risk of injury or contamination. Therefore, this action does not indicate correct performance of the skill.

Choice D Reason: Puts the Drop from Inner to Outer Canthus

Placing the drop from the inner to the outer canthus (corner of the eye) is a correct technique. This method helps ensure that the drop spreads evenly across the eye surface and reduces the risk of contamination. It also helps in preventing the dropper from touching the eye or eyelid, which can introduce bacteria. This action indicates correct performance of the skill.

Choice E Reason: Holds the Upper Eyelid Open When Placing the Drop

Holding the upper eyelid open when placing the drop is not the recommended technique. The proper method involves pulling down the lower eyelid to form a pocket and placing the drop into this pocket. Holding the upper eyelid open can cause discomfort and may not allow the drop to be placed accurately. Therefore, this action does not indicate correct performance of the skill.

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Correct Answer is C

Explanation

Choice A Reason: Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight and a distorted body image, leading to restricted food intake and excessive weight loss. Individuals with anorexia nervosa often have a relentless pursuit of thinness and may engage in extreme dieting, excessive exercise, and other behaviors to lose weight. While eliminating specific foods can be a part of anorexia nervosa, the primary focus is on weight loss and body image rather than the purity or healthiness of the food.

Choice B Reason: Rumination Disorder

Rumination disorder involves the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This condition is more common in infants and individuals with developmental disabilities but can occur in people of all ages. The behavior is typically involuntary and not related to concerns about food purity or healthiness. Therefore, it does not align with the client’s report of eliminating specific foods to “eat clean.”

Choice C Reason: Orthorexia

Orthorexia is an eating disorder characterized by an obsession with eating foods that one considers healthy or pure. Individuals with orthorexia may eliminate entire food groups, such as sugars, carbohydrates, or dairy, in their quest to maintain a “clean” diet6. This condition can lead to malnutrition and social isolation due to the restrictive nature of the diet. The client’s report of eliminating specific foods to “eat clean” is a clear indication of orthorexia.

A. Prevents extrapyramidal side effects. B. Reduces agitation until the lithium takes effect. C. Cures manic symptoms. D. Ensures high-quality sleep.

Correct Answer is B

Explanation

Choice A Reason: Prevents Extrapyramidal Side Effects

Extrapyramidal side effects (EPS) are drug-induced movement disorders that include symptoms such as tremors, rigidity, bradykinesia, and tardive dyskinesia. These side effects are commonly associated with first-generation antipsychotics. While second-generation antipsychotics like olanzapine have a lower risk of causing EPS, their primary use in this context is not to prevent these side effects. Therefore, this choice is not the most appropriate response to the family’s question.

Choice B Reason: Reduces Agitation Until the Lithium Takes Effect

Olanzapine is a second-generation antipsychotic that is effective in managing acute agitation and psychotic symptoms in patients with bipolar disorder. Lithium, while effective for long-term mood stabilization, takes several days to weeks to reach therapeutic levels and exert its full effect. During this period, olanzapine can help reduce the client’s agitation and stabilize their mood. This makes it the most appropriate response to the family’s question.

Choice C Reason: Cures Manic Symptoms

While olanzapine can help manage manic symptoms, it does not “cure” them. Bipolar disorder is a chronic condition that requires ongoing management with medications and therapy. The term “cure” is misleading as it implies a permanent resolution of symptoms, which is not the case with bipolar disorder. Therefore, this choice is not accurate.

Choice D Reason: Ensures High-Quality Sleep

Olanzapine can have sedative effects and may help improve sleep in some patients. However, its primary use in this scenario is to manage acute agitation and psychotic symptoms rather than to ensure high-quality sleep. While improved sleep may be a beneficial side effect, it is not the main reason for its prescription in this context.

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The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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