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Reason: An antifungal cream is not indicated for a sty, which is an infection of the eyelash follicle or sebaceous gland caused by bacteria.

Reason: Ice and cold compresses are not recommended for a sty, as they can constrict blood vessels and delay healing.

Reason: There is no need to test the other eye for vision loss, as a sty does not affect vision unless it is very large or obstructs the pupil.

Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection.

Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation.

Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions.

Reason: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves.

Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases.

Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection.

Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed.

Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing.

Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.

Reason: Inserting a nasal swab to observe the fluid is not recommended because it can potentially harm the patient. If the fluid draining from the nose is cerebrospinal fluid (CSF), which is a clear, colorless body fluid found in the brain and spinal cord, inserting a swab could introduce bacteria into this sterile environment. This could lead to serious complications such as meningitis, an inflammation of the membranes surrounding the brain and spinal cord.

Reason: Suctioning the nose gently with a bulb syringe is also not recommended. Again, if the fluid is CSF, suctioning could potentially draw bacteria up into the nasal cavity and into the brain, leading to an increased risk of infection. Additionally, suctioning could potentially cause trauma to the nasal passages, leading to further complications.

Reason: Allowing the drainage to drip onto a sterile gauze pad is the safest option. This method avoids the risk of introducing infection into the CSF and allows for the fluid to be tested to confirm if it is CSF. If the fluid is indeed CSF, this could indicate a basilar skull fracture, a serious injury that requires immediate medical attention.

Reason: Antibiotics are not contraindicated for a client with glaucoma and asthma, as they can treat or prevent infections that may affect the eye or the respiratory system.

Reason: NSAIDs are not contraindicated for a client with glaucoma and asthma, as they can reduce inflammation and pain that may affect the eye or the respiratory system.

Reason: Anticoagulants are not contraindicated for a client with glaucoma and asthma, as they can prevent or treat thromboembolic events that may affect the eye or the respiratory system.

Reason: This is incorrect because a client who is able to assist with transfer and perform self-care has a partial spinal cord injury, not a complete one. A partial spinal cord injury is a condition where there is some motor or sensory function below the level of injury. The degree of impairment depends on the extent and location of the damage.

Reason: This is incorrect because a client who is able to roll over independently has a lower spinal cord injury, not a complete one. A lower spinal cord injury is a condition where there is damage to the lumbar or sacral segments of the spinal cord. The client will have paralysis of the lower limbs (paraplegia) and some loss of bladder, bowel, and sexual function. The client will still have some control over the upper limbs and trunk.

Reason: This is incorrect because a client who is able to drive an electric wheelchair has an upper spinal cord injury, not a complete one. An upper spinal cord injury is a condition where there is damage to the cervical or thoracic segments of the spinal cord. The client will have paralysis of all four limbs (quadriplegia) and loss of bladder, bowel, and sexual function. However, the client may still have some movement or sensation in the shoulders, arms, or hands.

Reason: This is incorrect because a referral to a sleep study program is not the most appropriate plan of care for a blind client who has difficulty with sleep. A sleep study program is used to diagnose and treat sleep disorders such as sleep apnea, narcolepsy, or restless legs syndrome.

Reason: This is incorrect because assisting the client to see if a night shift job is available is not a helpful plan of care for a blind client who has difficulty with sleep. A night shift job can disrupt the circadian rhythm and worsen the sleep quality and quantity of the client.

Reason: This is incorrect because institution of opioids and sedatives is not a safe plan of care for a blind client who has difficulty with sleep. Opioids and sedatives can cause addiction, dependence, tolerance, and withdrawal symptoms. They can also impair the respiratory and cognitive functions of the client.

Reason: This is incorrect because dimming the lights in the client's room is not a helpful action for providing discharge teaching for a client who has hearing loss. Dimming the lights can reduce the visibility and clarity of the nurse's facial expressions, gestures, and lip movements, which can aid in communication.

Reason: This is incorrect because increasing the rate of speech when talking with the client is not an effective action for providing discharge teaching for a client who has hearing loss. Increasing the rate of speech can make it harder for the client to follow and understand what the nurse is saying.

Reason: This is incorrect because answering client's questions using medical terminology is not an appropriate action for providing discharge teaching for a client who has hearing loss. Medical terminology can be confusing and unfamiliar to the client, which can impair comprehension and learning.