A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina.
Which of the following statements by the client indicates an understanding of the teaching?
I can lift objects that are less than 10 pounds
I can resume activities, such as sewing
I can go jogging after 2 weeks
I should bend at the waist when putting on my shoes
The Correct Answer is A
The correct answer is A. I can lift objects that are less than 10 pounds.
Here's a breakdown of why the other options are incorrect:
- B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
- C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
- D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B, bradypnea. Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.
Choice A, euphoria, is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.
Euphoria is not a priority finding and does not indicate a serious complication of morphine.
Choice C, constipation, is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.
Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.
Choice D, sedation, is wrong because sedation is another common side effect of morphine that affects the central nervous system.
Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.
Correct Answer is D
Explanation
A. BP 150/92 mm Hg:
- This blood pressure reading is elevated and not a therapeutic effect of magnesium sulfate. In the context of preeclampsia, the goal is usually to lower blood pressure to prevent complications.
B. Pulse rate 100/min:
- The pulse rate of 100/min is not a specific therapeutic effect of magnesium sulfate. However, magnesium sulfate may cause a decrease in heart rate, so monitoring for bradycardia would be important.
C. Flushed face:
- A flushed face is not a specific therapeutic effect of magnesium sulfate. Facial flushing may be associated with other factors, but it is not a primary consideration when monitoring the effectiveness of magnesium sulfate in the context of preeclampsia.
D. Negative clonus:
- Negative clonus is the correct therapeutic effect to monitor. Clonus refers to a series of involuntary, rhythmic, and repetitive muscle contractions and relaxations. In the context of magnesium sulfate administration for preeclampsia, negative clonus (the absence of abnormal reflexes) is a sign that the magnesium levels are within the therapeutic range, helping to prevent seizures.
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