A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?
Stabilize the object
Apply anesthetic drops
Remove the object
Apply eye ointment
The Correct Answer is A
Choice A reason: This is the correct answer because stabilizing the object is the priority nursing action for a penetrating eye injury. Stabilizing the object prevents further damage to the eye structures and reduces the risk of infection and bleeding. The nurse should use a protective shield or cup to cover the eye and secure the object in place, and avoid applying any pressure or movement to the eye.
Choice B reason: This is not the correct answer because applying anesthetic drops is not the priority nursing action for a penetrating eye injury. Anesthetic drops may provide some relief from pain and discomfort, but they do not address the underlying problem of the object in the eye. Anesthetic drops should only be used under the direction of a physician, and after the object has been stabilized.
Choice C reason: This is not the correct answer because removing the object is not the priority nursing action for a penetrating eye injury. Removing the object is a surgical procedure that should only be performed by a qualified physician in a sterile environment. Attempting to remove the object by the nurse may cause more harm to the eye and increase the risk of complications.
Choice D reason: This is not the correct answer because applying eye ointment is not the priority nursing action for a penetrating eye injury. Eye ointment may interfere with the visualization and assessment of the eye, and may also contaminate the wound and cause infection. Eye ointment should only be used under the direction of a physician, and after the object has been stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Vitamin D is a fat-soluble vitamin that helps the body absorb calcium and phosphorus, which are essential for bone health. The main source of vitamin D is exposure to sunlight, which triggers the skin to produce it. The nurse should advise the client to spend at least 15 minutes outdoors every day, preferably in the morning or evening, when the sun is not too strong. The client should also wear sunscreen and protective clothing to prevent sunburn and skin damage.
Choice B reason: Reducing the amount of cereal in the diet is not a good recommendation for increasing vitamin D intake. Cereal is often fortified with vitamin D and other nutrients, such as iron and folic acid. The nurse should encourage the client to choose cereals that are high in vitamin D and low in sugar and fat. The client should also consume other foods that are rich in vitamin D, such as fatty fish, egg yolks, cheese, and mushrooms.
Choice C reason: Increasing intake of dietary calcium is important for preventing and treating osteoporosis, but it does not directly affect vitamin D intake. Calcium is a mineral that helps build and maintain strong bones and teeth. The nurse should recommend the client to consume foods that are high in calcium, such as dairy products, leafy greens, nuts, and tofu. The client should also take a calcium supplement if needed, as prescribed by the provider.
Choice D reason: Adding a regular exercise routine is beneficial for improving overall health and well-being, but it does not directly influence vitamin D intake. Exercise helps strengthen the muscles and bones, prevent falls and fractures, and reduce the risk of chronic diseases. The nurse should suggest the client to engage in moderate physical activity for at least 30 minutes a day, three times a week. The client should choose exercises that are appropriate for their age and fitness level, such as walking, swimming, or yoga.
Correct Answer is D
Explanation
Choice A reason: Identification is a defense mechanism where the person adopts the characteristics or behaviors of someone else, usually someone more powerful or successful, to cope with feelings of inadequacy or insecurity.
Choice B reason: Denial is a defense mechanism where the person refuses to accept or acknowledge the reality of a situation or a problem, to avoid dealing with the negative emotions or consequences.
Choice C reason: Displacement is a defense mechanism where the person transfers their feelings or impulses from the original source to a less threatening or more acceptable one, to reduce the anxiety or guilt.
Choice D reason: Rationalization is a defense mechanism where the person uses logical or plausible explanations to justify or excuse their actions or behaviors, to avoid facing the true motives or reasons.
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