A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Restrict head movement.

Remove eye patch in one month.

Apply cool compresses.

Eye drops to constrict the pupils will be prescribed.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Restricting head movement is a crucial preoperative instruction for a client scheduled for retinal detachment surgery. This helps to prevent further detachment and ensures that the retina remains in the best possible position for surgery. Keeping the head still minimizes the risk of additional damage and helps maintain the current state of the retina.

Choice B reason:

Removing an eye patch in one month is not a standard preoperative instruction. Eye patches are typically used postoperatively to protect the eye and aid in healing. The duration for wearing an eye patch varies depending on the specific case and the surgeon’s recommendations.

Choice C reason:

Applying cool compresses is not a typical preoperative instruction for retinal detachment surgery. Cool compresses are generally used to reduce swelling and discomfort postoperatively. Preoperative care focuses more on stabilizing the condition and preparing the client for surgery.

Choice D reason:

Eye drops to constrict the pupils are not commonly prescribed preoperatively for retinal detachment surgery. Instead, eye drops to dilate the pupils are often used to allow the surgeon a better view of the retina during the procedure. Pupil constriction is not typically necessary before surgery.

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Correct Answer is B

Explanation

Choice A reason: Babinski’s sign

Babinski’s sign is a reflex action where the big toe moves upward or toward the top surface of the foot and the other toes fan out when the sole of the foot is stimulated. This sign is used to assess neurological function, particularly in the context of central nervous system disorders. It is not related to hypocalcemia, which is the likely cause of the tingling sensation in this scenario.

Choice B reason: Chvostek’s sign

Chvostek’s sign is a clinical indicator of hypocalcemia. It is elicited by tapping the facial nerve at the angle of the jaw, which causes twitching of the facial muscles. Hypocalcemia is a common complication following thyroidectomy due to potential damage or removal of the parathyroid glands, which regulate calcium levels. The tingling sensation reported by the client is a classic symptom of hypocalcemia, making Chvostek’s sign the most relevant assessment.

Choice C reason: Brudzinski’s sign

Brudzinski’s sign is used to assess for meningitis. It involves flexing the client’s neck and observing for involuntary flexion of the hips and knees. This sign is not related to hypocalcemia or the symptoms described by the client following thyroidectomy.

Choice D reason: Kernig’s sign

Kernig’s sign is another test for meningitis. It involves flexing the client’s hip and knee, then straightening the knee. Pain and resistance to straightening the knee indicate a positive Kernig’s sign. This sign is not relevant to the assessment of hypocalcemia or the symptoms described by the client.

A. I will reduce my intake of vitamin K-rich foods. B. I will reduce my intake of sodium. C. I will decrease my intake of caffeine. D. I will limit my intake of soft drinks.

Correct Answer is A

Explanation

Choice A reason:

Reducing the intake of vitamin K-rich foods is not recommended for preventing osteoporosis. Vitamin K plays a crucial role in bone health by helping to regulate calcium in the bones and blood. It is essential for the formation of osteocalcin, a protein that binds calcium to the bone matrix, thereby strengthening bones1. Therefore, reducing vitamin K intake could negatively impact bone health.

Choice B reason:

Reducing sodium intake is beneficial for preventing osteoporosis. High sodium intake can lead to increased calcium excretion in the urine, which can weaken bones over time2. Lowering sodium intake helps to retain calcium in the body, promoting better bone health.

Choice C reason:

Decreasing caffeine intake is advisable for preventing osteoporosis. Excessive caffeine consumption can interfere with calcium absorption and increase calcium excretion, which can weaken bones. Limiting caffeine intake helps to ensure that more calcium is available for bone maintenance and strength.

Choice D reason:

Limiting the intake of soft drinks is also recommended for preventing osteoporosis. Many soft drinks contain phosphoric acid, which can lead to an imbalance in calcium and phosphorus levels in the body, potentially weakening bones. Reducing soft drink consumption helps to maintain a healthier balance of these minerals, supporting bone health.

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A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Nursing Test Bank

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