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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 A

Explanation

The correct answer is a. I feel so defeated and want to hide after I have binged.

Choice A Reason:

Individuals with binge-eating disorder often experience intense feelings of shame, guilt, and defeat after a binge episode. This emotional response is a hallmark of the disorder and can lead to further cycles of binge eating as a way to cope with these negative emotions. The statement “I feel so defeated and want to hide after I have binged” accurately reflects the emotional turmoil that accompanies binge-eating episodes.

Choice B Reason:

The statement “I am able to control the pace of my bingeing when I start getting full” is not typically associated with binge-eating disorder. People with this disorder often feel a loss of control over their eating during a binge episode and are unable to stop even when they are full. This lack of control is a key diagnostic criterion for binge-eating disorder.

Choice C Reason:

While feeling hungry can trigger a binge, it is not the primary characteristic of binge-eating disorder. The disorder is more about the uncontrollable nature of the eating episodes and the emotional distress that follows, rather than just responding to hunger. Therefore, the statement “My binges usually start off with feeling hungry” does not fully capture the essence of the disorder.

Choice D Reason:

Binge-eating as a reward for completing difficult tasks is not a typical feature of binge-eating disorder. The disorder is more about using food as a way to cope with negative emotions rather than as a reward. The statement “I binge to reward myself for completing difficult tasks” does not align with the common emotional triggers for binge-eating episodes.

A. Apply restraints. B. Identify social supports. C. Replace fluids. D. Orient to reality.

Correct Answer is C

Explanation

The correct answer is c. Replace fluids.

Choice A Reason: Apply restraints

Applying restraints is generally not the first-line intervention for managing alcohol withdrawal. Restraints should only be used if the patient poses an immediate threat to themselves or others and all other less restrictive measures have failed. The primary focus in the initial phase of alcohol withdrawal is to manage physiological stability and prevent complications.

Choice B Reason: Identify social supports

While identifying social supports is important for long-term recovery and overall mental health, it is not the highest priority during the initial phase of alcohol withdrawal. The immediate concern is to address the acute physiological symptoms and prevent severe complications such as seizures or delirium tremens.

Choice C Reason: Replace fluids

Replacing fluids is the highest priority in the initial phase of alcohol withdrawal. Dehydration is a common issue in patients undergoing withdrawal, and maintaining fluid balance is crucial for preventing complications. Ensuring adequate hydration helps stabilize the patient and supports overall physiological function during the withdrawal process.

Choice D Reason: Orient to reality

Orienting the patient to reality is important, especially if they are experiencing confusion or delirium. However, it is not the highest priority in the initial phase of alcohol withdrawal. The primary focus should be on stabilizing the patient’s physiological condition, including fluid replacement and monitoring vital signs.

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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

A nurse is caring for a client who has a binge-eating disorder. Which of the following statements should the nurse expect from this client?

Correct Answer is A

Explanation

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Correct Answer is C

Explanation

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