The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Why Safety Comes First
- The client presents with multiple red flags for physical abuse and neglect, including bruises in various stages of healing, a fracture, and concerning behavior around the adult child.
- Ensuring the client is in a safe environment is the top priority to prevent further harm and initiate protective interventions.
Why Nutritional Status Is Next
- The client reports limited food availability and has a low BMI (18.3), suggesting possible malnutrition.
- Addressing nutritional needs is essential for recovery and overall well-being, especially in older adults who are vulnerable to rapid health decline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Dark spots or floaters in vision are not a typical post-operative finding for cataract removal. They are more commonly associated with retinal detachment, which is a rare but serious complication. The client should be instructed to report this to the provider immediately.
Choice B rationale
Bruising of the eyelids is not a normal or expected outcome after cataract surgery. The procedure is typically performed with a small incision and does not cause significant trauma to the surrounding tissues, making bruising an uncommon occurrence.
Choice C rationale
Cataract surgery is almost always performed using a local anesthetic, not general anesthesia. A local anesthetic is administered to numb the eye and surrounding area, allowing the client to remain awake and aware during the procedure while feeling no pain.
Choice D rationale
The fundamental principle of cataract surgery is the removal of the clouded, opaque lens and its replacement with a clear, artificial intraocular lens (IOL). This is the definitive treatment for cataracts, restoring visual clarity and function to the eye. *.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Verifying the clarity and color of the eye drops is a critical safety step to ensure the medication has not been compromised. Eye drops should be clear and colorless unless specified otherwise. Any discoloration or particulate matter indicates that the solution may be contaminated or expired and should not be administered, preventing potential harm or infection to the client.
Choice B rationale
Pulling the lower lid down creates a small pocket, or conjunctival sac, which is the proper site for medication administration. This technique prevents the eye drops from immediately flowing out of the eye, allowing for maximum absorption of the medication. It also protects the cornea from direct injury by the applicator, which can be sensitive and easily scratched.
Choice C rationale
Applying gentle pressure to the punctum, the small opening in the corner of the eye, for 30 to 60 seconds after instillation prevents systemic absorption of the medication. This is particularly important for drugs like timolol, a beta-blocker, as systemic absorption can lead to adverse effects on the heart and lungs, such as bradycardia and bronchospasm.
Choice D rationale
Tilting the client's head backward facilitates proper administration by allowing gravity to assist in directing the eye drop into the conjunctival sac. This position also helps to prevent the drop from immediately rolling out of the eye or onto the client's cheek, ensuring the medication is retained in the correct location for therapeutic effect.
Choice E rationale
Administering the prescribed number of drops directly into the conjunctival sac ensures the client receives the correct dosage. The nurse should avoid touching the tip of the dropper to the client's eye or eyelashes to prevent cross-contamination of the bottle. This step is essential for both the therapeutic efficacy and safety of the medication administration. *.
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