A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?
Apply cool compresses.
Eye drops to constrict the pupils will be prescribed.
Restrict head movement.
Keep both eyes patched.
The Correct Answer is C
Choice A rationale
Applying cool compresses can help reduce swelling and discomfort, but it is not the primary instruction for a client scheduled for retinal detachment surgery.
Choice B rationale
Eye drops to constrict the pupils are not typically prescribed for retinal detachment surgery. The focus is on preventing further detachment and ensuring proper healing.
Choice C rationale
Restricting head movement is crucial to prevent further detachment of the retina and to promote proper healing after surgery. The client should be instructed to avoid sudden or excessive head movements.
Choice D rationale
Keeping both eyes patched is not necessary and may cause unnecessary discomfort and disorientation for the client.
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Correct Answer is D
Explanation
Choice A rationale
Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.
Choice B rationale
Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.
Choice C rationale
Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.
Choice D rationale
Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.
Correct Answer is C
Explanation
Choice A rationale
White drainage on the eyelids is not a normal finding and should be reported to the surgeon. However, this is not a standard discharge instruction but rather a sign of potential infection.
Choice B rationale
Sleeping on the abdomen is not recommended after cataract surgery as it can increase pressure on the eye and disrupt healing. Patients are usually advised to sleep on their back or the unaffected side.
Choice C rationale
Avoiding lifting anything heavier than 4.5 kg (10 lb) for 1 week is a standard instruction to prevent increased intraocular pressure and ensure proper healing of the surgical site.
Choice D rationale
Bending at the waist to pick up objects can increase intraocular pressure and should be avoided. Patients are advised to bend at the knees instead.