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The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

Puts the eye drops in a room with low lighting

Washes their hands before placing the eye drops

Uses the patient’s iris as a landmark for direct placement of the drop

Puts the drop from inner to outer canthus

Holds the upper eyelid open when placing the drop

Answer and Explanation

Correct Answer : B,D

b. Washes their hands before placing the eye drops

d. Puts the drop from inner to outer canthus

Explanation of Choices

Choice A Reason: Puts the Eye Drops in a Room with Low Lighting

Administering eye drops in a room with low lighting is not a recommended practice. Proper lighting is essential to ensure accurate placement of the drops and to avoid contamination or injury. Low lighting can make it difficult to see the eye and the dropper, increasing the risk of improper administration. Therefore, this action does not indicate correct performance of the skill.

Choice B Reason: Washes Their Hands Before Placing the Eye Drops

Washing hands before administering eye drops is a crucial step to prevent infection and contamination. Clean hands reduce the risk of transferring bacteria or other pathogens to the eye, which can cause infections or other complications. This action is a fundamental part of proper eye drop administration and indicates correct performance of the skill.

Choice C Reason: Uses the Patient’s Iris as a Landmark for Direct Placement of the Drop

Using the patient’s iris as a landmark for direct placement of the drop is incorrect. The proper technique involves pulling down the lower eyelid to create a small pocket (conjunctival sac) and placing the drop into this pocket. Directly aiming for the iris can cause discomfort and increase the risk of injury or contamination. Therefore, this action does not indicate correct performance of the skill.

Choice D Reason: Puts the Drop from Inner to Outer Canthus

Placing the drop from the inner to the outer canthus (corner of the eye) is a correct technique. This method helps ensure that the drop spreads evenly across the eye surface and reduces the risk of contamination. It also helps in preventing the dropper from touching the eye or eyelid, which can introduce bacteria. This action indicates correct performance of the skill.

Choice E Reason: Holds the Upper Eyelid Open When Placing the Drop

Holding the upper eyelid open when placing the drop is not the recommended technique. The proper method involves pulling down the lower eyelid to form a pocket and placing the drop into this pocket. Holding the upper eyelid open can cause discomfort and may not allow the drop to be placed accurately. Therefore, this action does not indicate correct performance of the skill.

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Correct Answer is B

Explanation

The correct answer is b. Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.

Choice A Reason: Get the defibrillator to the patient’s bedside and open the crash cart

While having the defibrillator and crash cart ready is important in emergency situations, it is not the immediate priority in this scenario. The patient’s symptoms suggest opioid overdose, which requires immediate intervention to support breathing and reverse the effects of the opioid. The primary focus should be on ensuring adequate oxygenation and administering naloxone.

Choice B Reason: Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone

This is the correct answer. The patient’s blue-tinged lips, slowed respirations, and pinpoint pupils are indicative of opioid overdose. Administering oxygen via a 100% nonrebreather mask helps to ensure adequate oxygenation, while placing an IV catheter allows for the administration of naloxone, an opioid antagonist that can reverse the effects of the overdose. This intervention addresses the immediate life-threatening condition.

Choice C Reason: Administer naloxone intranasally if there is not an IV catheter in place

While administering naloxone intranasally is an appropriate alternative if IV access is not available, it is not the first priority. The initial focus should be on ensuring adequate oxygenation and establishing IV access for more effective administration of naloxone. If IV access cannot be quickly established, then intranasal naloxone can be used.

Choice D Reason: Contact the patient’s parents or legal guardian for consent to treat

Obtaining consent is important, but it is not the immediate priority in a life-threatening situation. The nurse’s primary responsibility is to stabilize the patient and address the acute medical emergency. Once the patient is stabilized, the nurse can then contact the parents or legal guardian for further consent and information.

A. The diathesis-stress model assists the client in identifying their level of stress or anxiety. B. The diathesis-stress model assists in telling me how stressed a client is. C. The diathesis-stress model assists in identifying risk factors or vulnerabilities for stress. D. The diathesis-stress model assists in identifying what mental health disorder related to stress the client has.

Correct Answer is C

Explanation

Choice A Reason: The diathesis-stress model assists the client in identifying their level of stress or anxiety.

This statement is incorrect because the diathesis-stress model does not primarily focus on helping clients identify their current levels of stress or anxiety. Instead, it is a framework used to understand how predispositional vulnerabilities (diatheses) and external stressors interact to influence the development of psychological disorders. While understanding stress levels can be part of a broader assessment, it is not the main purpose of the diathesis-stress model.

Choice B Reason: The diathesis-stress model assists in telling me how stressed a client is.

This statement is also incorrect. The diathesis-stress model is not a tool for measuring or quantifying a client’s current stress levels. Rather, it is a theoretical model that explains how stress interacts with an individual’s vulnerabilities to potentially trigger mental health issues. The model helps clinicians understand the interplay between genetic, biological, and environmental factors, but it does not provide a direct measure of stress.

Choice C Reason: The diathesis-stress model assists in identifying risk factors or vulnerabilities for stress.

This statement is correct. The diathesis-stress model is designed to identify and understand the risk factors or vulnerabilities (diatheses) that make an individual more susceptible to developing psychological disorders when exposed to stress. These vulnerabilities can be genetic, biological, psychological, or situational. By identifying these factors, clinicians can better predict which individuals are at higher risk for developing mental health issues under stress and can tailor interventions accordingly.

Choice D Reason: The diathesis-stress model assists in identifying what mental health disorder related to stress the client has.

This statement is partially correct but not entirely accurate. While the diathesis-stress model can help in understanding the development of mental health disorders, it does not specifically identify which disorder a client has. The model provides a framework for understanding how various factors contribute to the onset of disorders, but a comprehensive clinical assessment is required to diagnose specific mental health conditions.

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The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?

Correct Answer is B

Explanation

A nurse is discussing the diathesis-stress model with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the model?

Correct Answer is C

Explanation

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