ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 42 Questions
Question 1 of 5
A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client?
Correct Answer: A
Rationale: Blepharitis is an inflammation of the lid margins. The nurse monitors visible patchy flakes clinging to the eyelashes and about the lids. The condition does not cause redness or a halo around the pupil. In case of a sty, the nurse would observe a red pustule in the internal tissue of the eyelid.
Question 2 of 5
An eighth-grade client visits the school nurse and reports having been to an eye doctor who identified an astigmatism and described it as a condition in which the eyeball is not shaped correctly. The client asks the nurse why both eyes look alike in the mirror if this is the case. What is the nurse's best response?
Correct Answer: A
Rationale: Astigmatism is visual distortion caused by an irregularly shaped cornea. When the overall shape of the eye is like an olive, or more oblong, it results in myopia, not astigmatism, although both conditions may be present at once. The inside of the eye is not shaped differently in the client with an astigmatism. The overall shape of the eye being shorter results in hyperopia, not astigmatism.
Question 3 of 5
Following cataract removal, the client receives discharge instructions from the nurse. Which of the following instructions is most important?
Correct Answer: D
Rationale: For at least 1 week, the client should avoid strenuous activity and heavy lifting; bending, stooping, or other exercises that potentially increase intraocular pressure; immersing the eyes in water (clients may use a clean damp cloth to remove any eye discharge); and any activity that could cause dust or other particles to lodge in the eye. Clients may sleep on the back or unaffected side. The client should wear a protective eye shield for 24 hours after the procedure and then at night and during naps for about a week.
Therefore, it is insufficient for the nurse to instruct the client to wear a protective shield at bedtime.
Question 4 of 5
A nurse is caring for a client who has undergone enucleation. What complication of enucleation should be addressed by the nurse?
Correct Answer: C
Rationale: The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting are common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.
Question 5 of 5
A nurse is caring for a client newly diagnosed with glaucoma. Which would be a priority in the nurse's teaching about maintaining normal pressure range in the eye?
Correct Answer: A
Rationale: Adding fiber to the diet will increase ease of bowel movements and prevent constipation and straining, which can inadvertently increase intraocular pressure. Eating small meals is insignificant in maintaining intraocular pressure. Avoid over-the-counter treatment of cold and allergy symptoms if contains cholinergic blockers. Reading is not significant in changing intraocular pressure, but eye strain should be avoided.