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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Their full therapeutic potential may not be reached until 4 weeks
This statement is correct. Tricyclic antidepressants (TCAs) often take several weeks to reach their full therapeutic effect. Patients may start to notice some improvement within one to two weeks, but it can take up to four weeks or longer for the full benefits to be realized1. This delayed onset is due to the time it takes for the medication to build up in the system and exert its effects on neurotransmitter levels.
Choice B Reason: Aged cheese should not be eaten while taking them
This statement is incorrect. The dietary restriction of avoiding aged cheese is associated with monoamine oxidase inhibitors (MAOIs), not tricyclic antidepressants. MAOIs can cause dangerous interactions with tyramine, a substance found in aged cheese and other foods, leading to hypertensive crises. TCAs do not have this dietary restriction.
Choice C Reason: They should not be given with antianxiety agents
This statement is incorrect. Tricyclic antidepressants can be used in conjunction with antianxiety agents under medical supervision. However, it is important to monitor for potential interactions and side effects. The combination can be beneficial for patients with comorbid depression and anxiety disorders.
Choice D Reason: They may cause hypomania or recent memory impairment
This statement is partially correct but not the best indicator of understanding. While TCAs can cause side effects such as memory impairment and, in rare cases, hypomania, these are not the primary concerns when teaching about the medication. The focus should be on understanding the therapeutic timeline and common side effects.
Correct Answer is A
Explanation
a. Cardiac dysrhythmia resulting in cardiac arrest
Explanation of Choices
Choice A Reason: Cardiac Dysrhythmia Resulting in Cardiac Arrest
Cardiac dysrhythmias, or irregular heartbeats, are a significant health complication associated with anorexia nervosa. These dysrhythmias can result from electrolyte imbalances, particularly low potassium levels (hypokalemia), which are common in individuals with anorexia due to malnutrition and purging behaviors. Severe dysrhythmias can lead to cardiac arrest, making this one of the most critical and potentially fatal complications of anorexia nervosa. The heart muscle can weaken due to prolonged malnutrition, leading to a condition known as myocardial atrophy, which further increases the risk of cardiac complications.
Choice B Reason: Endocrine Imbalance Causing Amenorrhea
Amenorrhea, or the absence of menstruation, is a common endocrine complication in females with anorexia nervosa. This condition occurs due to the body’s response to severe weight loss and malnutrition, which disrupts the normal production of reproductive hormones. While amenorrhea is a significant health issue, it is not as immediately life-threatening as cardiac dysrhythmias. Amenorrhea can lead to long-term complications such as infertility and osteoporosis but does not typically result in acute medical emergencies.
Choice C Reason: Decreased Metabolism Causing Cold Intolerance
Decreased metabolism and cold intolerance are common symptoms in individuals with anorexia nervosa. The body reduces its metabolic rate in response to prolonged starvation to conserve energy. This can lead to a lower body temperature and increased sensitivity to cold. While uncomfortable and indicative of severe malnutrition, decreased metabolism and cold intolerance are not as immediately dangerous as cardiac dysrhythmias. These symptoms reflect the body’s adaptation to a state of energy deficiency but do not pose an immediate threat to life.
Choice D Reason: Glucose Intolerance Resulting in Hypoglycemia
Hypoglycemia, or low blood sugar, can occur in individuals with anorexia nervosa due to inadequate food intake. However, glucose intolerance and hypoglycemia are less common and less severe complications compared to cardiac dysrhythmias. Hypoglycemia can cause symptoms such as dizziness, confusion, and fainting, but it is typically manageable with appropriate nutritional support. It does not carry the same immediate risk of fatality as cardiac dysrhythmias.
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