A nurse at an ophthalmology clinic is providing medication teaching to a client who has open-angle glaucoma. Which of the following instructions should the nurse provide?

Apply the medication when you are experiencing eye pain

Use the medication only until the intraocular pressure returns to normal

Use the medication for approximately 10 days, then gradually taper off

Apply the medication on a regular schedule for the rest of your life

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect because applying the medication when you are experiencing eye pain can be ineffective or harmful for treating open-angle glaucoma. Open-angle glaucoma is a chronic condition that causes increased pressure inside the eye and damage to the optic nerve, which can lead to vision loss. Eye pain is not a common symptom of open-angle glaucoma, but rather an indication of acute angle closure glaucoma, which is a medical emergency that requires immediate treatment. The nurse should instruct the client to apply the medication as prescribed, regardless of pain level, and seek medical attention if they experience severe eye pain, headache, nausea, or blurred vision.
Choice B reason: This is incorrect because using the medication only until the intraocular pressure returns to normal can cause recurrence or worsening of open-angle glaucoma. Intraocular pressure is the pressure inside
the eye that can affect eye health and vision. Normal intraocular pressure ranges from 10 to 21 mmHg, but it can vary depending on age, time of day, or other factors. The nurse should instruct the client to monitor their intraocular pressure regularly and report any changes to their provider, but not to stop using
the medication without consulting their provider first.
Choice C reason: This is incorrect because using the medication for approximately 10 days, then gradually tapering off can cause rebound or adverse effects of open-angle glaucoma. The medication for open-angle glaucoma can be either beta-blockers, such as timolol, or cholinergic agents, such as pilocarpine, which work by reducing fluid production or increasing fluid drainage in the eye. The nurse should instruct the client to follow their provider's instructions on how long and how much to use the medication and not to change or discontinue it abruptly without their provider's approval.
Choice D reason: This is correct because applying the medication on a regular schedule for the rest of your life can help control and prevent the progression of open-angle glaucoma. Open-angle glaucoma is a lifelong condition that requires consistent and continuous treatment to maintain normal intraocular pressure and prevent vision loss. The nurse should instruct the client to apply the medication at the same time every day and not to miss or skip any doses. The nurse should also teach the client how to store, handle, and administer the medication properly and safely.

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Correct Answer is B

Explanation

Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.

Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.

Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.

Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.

A. Airway obstruction. B. Fluid imbalance. C. Paralytic ileus. D. Infection.

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because airway obstruction is the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Airway obstruction can occur due to edema, inflammation, or inhalation injury of
the upper airway structures. It can compromise oxygenation and ventilation, and lead to respiratory failure or cardiac arrest. The nurse should assess for signs of airway obstruction, such as stridor, hoarseness, dyspnea, or cyanosis, and provide oxygen therapy, humidification, or intubation as needed.

Choice B reason: This is incorrect because fluid imbalance is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Fluid imbalance can occur due to fluid loss from damaged skin and capillaries, as well as increased capillary permeability and fluid shifts. It can cause dehydration, hypovolemia, shock, or electrolyte imbalances. The nurse should monitor fluid status, vital signs, urine output, and laboratory values, and provide fluid resuscitation as prescribed, but only after ensuring airway patency.

Choice C reason: This is incorrect because paralytic ileus is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Paralytic ileus is a condition where there is decreased or absent bowel motility due to nerve damage or decreased blood flow to
the gastrointestinal tract. It can cause abdominal distension, nausea, vomiting, or constipation. The nurse should assess bowel sounds, abdominal girth, and stool characteristics, and provide nasogastric suction or laxatives as prescribed, but only after ensuring airway patency and fluid balance.

Choice D reason: This is incorrect because infection is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Infection can occur due to loss of skin barrier, exposure to microorganisms, or impaired immune system. It can cause fever, increased pain, purulent drainage, or sepsis. The nurse should assess for signs of infection, obtain wound cultures, and administer antibiotics as prescribed, but only after ensuring airway patency, fluid balance, and pain control.

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A nurse at an ophthalmology clinic is providing medication teaching to a client who has open-angle glaucoma. Which of the following instructions should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Correct Answer is B

Explanation

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns on the head, neck, and chest. The nurse should identify which of the following risks is the priority for assessment and intervention.

Correct Answer is A

Explanation

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