A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
Administer the medications 5 minutes apart.
Hold pressure on the conjunctival sac for 2 minutes following application of drops.
It is not necessary to remove contact lenses before administering medications.
Administer the medications by touching the tip of the dropper to the sclera of the eye.
The Correct Answer is A
Choice A: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.
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Correct Answer is A
Explanation
Choice A: Flu-like symptoms and night sweats
The initial symptoms of HIV infection often resemble those of the flu. These symptoms, known as acute retroviral syndrome (ARS) or primary HIV infection, typically occur within 2 to 4 weeks after the virus enters the body. Common symptoms include fever, chills, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, and a rash. These symptoms are the body’s natural response to the virus and indicate that the immune system is reacting to the infection. Night sweats, in particular, are a common symptom during the early stages of HIV infection.
Choice B: Fungal and bacterial infections
Fungal and bacterial infections are more commonly associated with later stages of HIV infection, particularly when the immune system has been significantly weakened. As HIV progresses and the immune system deteriorates, individuals become more susceptible to opportunistic infections, which are infections that occur more frequently and are more severe in people with weakened immune systems. These infections are not typically seen in the initial stages of HIV infection.
Choice C: Pneumocystis lung infection
Pneumocystis pneumonia (PCP) is a serious infection that occurs in people with weakened immune systems, including those with advanced HIV/AIDS. It is caused by the fungus Pneumocystis jirovecii. PCP is not an initial symptom of HIV infection but rather a complication that can arise when the immune system is severely compromised. This infection is more indicative of the later stages of HIV, particularly when the CD4 cell count drops significantly.
Choice D: Kaposi’s sarcoma
Kaposi’s sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. It is caused by the human herpesvirus 8 (HHV-8) and is commonly associated with advanced HIV infection or AIDS. Kaposi’s sarcoma presents as purple, red, or brown blotches or tumors on the skin and can also affect internal organs. This condition is not an initial symptom of HIV infection but rather a manifestation of severe immune system damage in the later stages of the disease.
Correct Answer is A
Explanation
Choice A reason: Place a pillow under the client’s head:
During a tonic-clonic seizure, it is crucial to protect the client’s head from injury. Placing a pillow or any soft object under the head can help prevent head trauma caused by the convulsions. Ensuring the client’s safety by protecting their head is a primary concern during a seizure.
Choice B reason: Insert a padded tongue blade into the client’s mouth:
This action is incorrect and potentially dangerous. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or jaw. It can also obstruct the airway. The myth that a person can swallow their tongue during a seizure is false, and no object should be placed in the mouth.
Choice C reason: Apply a face mask for oxygen administration:
While providing oxygen can be beneficial after the seizure has ended, during the seizure, the priority is to ensure the client’s safety and prevent injury. Applying a face mask during the active phase of a seizure is not practical and can interfere with managing the seizure safely.
Choice D reason: Gently restrain the client’s extremities:
Restraining the client’s extremities during a seizure is not recommended. Attempting to restrain the movements can cause injury to both the client and the nurse. The focus should be on protecting the client from harm without restricting their movements.