A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
"It's hard to see with a patch on one eye. I'm afraid of falling."
"My eye really itches, but I'm trying not to rub it."
"The bright light in this room is really bothering me."
"I need something for the pain in my eye. I can't stand it."
The Correct Answer is D
Choice A reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have reduced vision and an increased risk of falling with a patch on one eye after cataract surgery. The nurse should reassure the client, provide assistance with mobility, and educate the client on safety measures.
Choice B reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have some itching and discomfort in the eye after cataract surgery. The nurse should commend the client for not rubbing the eye, as this can cause infection or damage to the surgical site. The nurse should also administer anti-inflammatory eye drops as prescribed and instruct the client on how to apply them.
Choice C reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have increased sensitivity to light in the eye after cataract surgery. The nurse should dim the lights in the room, provide sunglasses or a shield for the eye, and educate the client on how to protect the eye from bright light.
Choice D reason: This is the correct answer because this comment requires reporting to the client's provider. Severe pain in the eye after cataract surgery can indicate a complication such as infection, inflammation, bleeding, or increased intraocular pressure. The nurse should assess the eye for signs of redness, swelling, discharge, or bleeding, and report the findings and the pain level to the provider. The nurse should also administer analgesics as prescribed and monitor the pain relief.
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 correct because macular degeneration is a condition that affects the macula, which is the central part of the retina that is responsible for sharp and detailed vision. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field.
Choice B Reason: This is incorrect because glaucoma is a condition that affects the optic nerve, which is the nerve that connects the eye to the brain and carries visual signals. Glaucoma can cause increased pressure inside the eye, damage to the optic nerve, and loss of peripheral vision.
Choice C Reason: This is incorrect because diabetic retinopathy is a condition that affects the blood vessels in the retina, which is the layer of tissue at the back of the eye that converts light into nerve impulses. Diabetic retinopathy can cause bleeding, swelling, or leakage of fluid in the retina, and loss of vision in any part of the visual field.
Choice D Reason: This is incorrect because cataract is a condition that affects the lens, which is the transparent structure behind the pupil that focuses light onto the retina. Cataract can cause clouding or opacity of the lens, and reduced vision in all parts of the visual field.
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