A nurse is collecting data from a client who has a suspected cataract. The nurse should collect data from which of the following areas to confirm the diagnosis?
The client’s tongue
The client’s eyelid
The lens of the client’s eye
The posterior pharynx of the client’s throat
The Correct Answer is C
Choice A Reason:
The client’s tongue is not relevant for diagnosing cataracts. Cataracts are an eye condition characterized by clouding of the lens, which affects vision. The tongue does not provide any information related to the presence of cataracts.
Choice B Reason:
The client’s eyelid is also not relevant for diagnosing cataracts. While the eyelid can be examined for other eye-related conditions, it does not provide information about the lens’s clarity or the presence of cataracts. Cataracts specifically affect the lens inside the eye.
Choice C Reason:
The lens of the client’s eye is the correct area to examine for diagnosing cataracts. Cataracts cause the lens to become cloudy, leading to symptoms such as blurred vision, difficulty seeing at night, and sensitivity to light. An eye examination, including a slit-lamp exam, allows the healthcare provider to see the lens and identify any cloudiness or opacities indicative of cataracts.
Choice D Reason:
The posterior pharynx of the client’s throat is not relevant for diagnosing cataracts. This area is examined for conditions related to the throat and respiratory system, not for eye conditions. Cataracts are diagnosed through an eye examination focusing on the lens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Preparing the patient for immediate surgical intervention is not the first-line treatment for hemophilia-related joint bleeding. Surgery is considered only if there is severe damage or if conservative measures fail. Initial management focuses on controlling bleeding and reducing inflammation.
Choice B Reason:
Administering aspirin for pain relief is contraindicated in patients with hemophilia. Aspirin inhibits platelet function and can exacerbate bleeding. Alternative pain management strategies that do not affect clotting should be used.
Choice C Reason:
Applying ice to the affected knee and elevating the leg is the most appropriate initial intervention. Ice helps to reduce swelling and pain, while elevation minimizes blood flow to the area, helping to control bleeding. This conservative approach is crucial in managing acute hemarthrosis in hemophilia patients.
Choice D Reason:
Performing passive range of motion exercises on the affected knee is not recommended during the acute phase of hemarthrosis. Movement can increase bleeding and worsen the condition. Rest and immobilization are preferred until the bleeding is controlled.
Correct Answer is A
Explanation
Choice A Reason:
Tilting the head to the side and pulling the earlobe up and back is the recommended method for adults to straighten the ear canal, allowing the drops to flow directly into the ear canal and reach the site of infection effectively. This method ensures that the medication is properly administered and can work effectively to treat the infection.
Choice B Reason:
Laying flat on your back and placing the drops on a cotton ball before inserting it into the ear canal is not a recommended method for administering ear drops. This method can prevent the medication from reaching the ear canal properly and may not be as effective in treating the infection. Additionally, using a cotton ball can absorb the medication, reducing its effectiveness.
Choice C Reason:
Tilting the head to the side and pulling the earlobe down and back is the correct method for administering ear drops to children under three years old. For adults, this method is not recommended as it does not straighten the ear canal properly, which can prevent the medication from reaching the site of infection effectively.
Choice D Reason:
Tilting the head forward and pulling the earlobe up and forward is not a recommended method for administering ear drops. This method does not properly straighten the ear canal and can prevent the medication from reaching the site of infection. It is important to follow the correct technique to ensure the medication is effective.
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