A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client’s provider?
“My eye really itches, but I’m trying not to rub it.”.
“The bright light in this room is really bothering me.”.
“I’m afraid of falling.”.
“I need something for the pain in my eye.
The Correct Answer is D
Choice A rationale
Itching is a common symptom after cataract surgery, and the client should be reminded not to rub or place pressure on the eyes. This comment does not indicate a serious complication.
Choice B rationale
Sensitivity to bright light is also common after cataract surgery. The client can be advised to wear sunglasses to reduce discomfort. This comment does not indicate a serious complication.
Choice C rationale
Fear of falling is a valid concern, especially if the client has impaired vision or depth perception due to the eye patch. However, this comment does not indicate a serious complication that needs immediate reporting.
Choice D rationale
Severe pain in the eye after cataract surgery can indicate a complication such as increased intraocular pressure, infection, or hemorrhage. This comment should be reported to the provider immediately for further evaluation and intervention.
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Correct Answer is D
Explanation
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
Correct Answer is C
Explanation
Choice A rationale
Dysphagia, or difficulty swallowing, is not a common manifestation of acoustic neuroma. It is more commonly associated with conditions affecting the throat or esophagus.
Choice B rationale
Apraxia, a motor disorder caused by damage to the brain, is not typically associated with acoustic neuroma. It affects the ability to perform coordinated movements.
Choice C rationale
Vertigo, or a sensation of spinning, is a common manifestation of acoustic neuroma. The tumor affects the vestibular nerve, which is responsible for balance and spatial orientation.
Choice D rationale
Diplopia, or double vision, is not a common symptom of acoustic neuroma. It is more often associated with conditions affecting the muscles or nerves controlling eye movement.