A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?
"Take a stool softener daily."
"You can lift objects that weigh 15 pounds."
"Avoid reading for 3 days following surgery."
"Pick up items by bending at the waist."
The Correct Answer is A
Rationale:
A. "Take a stool softener daily.": Preventing straining during bowel movements is critical after retinal surgery because increased intraocular pressure from straining can disrupt the surgical repair. Stool softeners help maintain soft stools and reduce the risk of increased eye pressure.
B. "You can lift objects that weigh 15 pounds.": Clients should avoid heavy lifting after retinal surgery to prevent increased intraocular pressure. The amount of weight considered safe is minimal, and lifting anything heavier can compromise the surgical site.
C. "Avoid reading for 3 days following surgery.": Light visual activities like reading are usually permitted after surgery, depending on provider instructions. Complete restriction is unnecessary, though clients should avoid activities that increase eye strain or involve prolonged downward gaze.
D. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure, which can compromise the retina. Clients should be instructed to bend at the knees and keep the head upright when picking up objects to protect the surgical repair.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. "I understand that my scars will eventually fade.": This statement reflects acceptance and understanding of the healing process rather than distress about appearance. It indicates the client is cognitively processing changes without expressing body image disturbance.
B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group demonstrates coping and adjustment. The client is seeking social and emotional support, which is a healthy response to surgery rather than a sign of altered body image.
C. "I want to have reconstructive surgery as soon as I can.": Desire for reconstructive surgery is a proactive coping strategy and a way to regain body image control. It reflects planning for recovery rather than expressing negative feelings about current body changes.
D. "I prefer to leave the lights off when I am changing my clothes.": Avoiding exposure of the body and seeking darkness when changing clothes indicates discomfort and distress with physical appearance. This behavior reflects an altered body image and difficulty accepting the changes after surgery.
Correct Answer is B
Explanation
Rationale:
A. "Can you tell me more about the surgery I am having?": Before signing consent, the client should already have received complete information about the nature, purpose, risks, and benefits of the surgery from the provider.
B. "Signing this form indicates that I give my permission for the surgery, right?": Informed consent is a legal and ethical document granting permission for the procedure. It shows that the client comprehends their role in authorizing the surgery after receiving adequate information from the healthcare provider.
C. "I will talk with the doctor about my surgery when I get into the operating room.": Consent discussions should occur before entering the operating room. The client must have all questions answered and sign consent prior to sedation or anesthesia to ensure voluntary decision-making.
D. "Every so often, I think about whether or not to have this surgery.": This response suggests indecision and lack of informed readiness for the procedure. The nurse must notify the provider so further discussion can occur to address concerns and ensure the client’s consent is fully informed and voluntary.
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