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 C
Explanation
Choice A rationale
Drinking room temperature beverages can help minimize irritation in the mouth and throat, which is beneficial for clients with stomatitis. Cold or hot beverages can exacerbate the condition by causing discomfort and pain.
Choice B rationale
Taking a prescribed analgesic can help manage the pain associated with stomatitis. Pain management is crucial for maintaining the client’s comfort and ability to eat and drink.
Choice C rationale
Stomatitis is not contagious and cannot be spread to family members. This statement indicates a need for further teaching as it reflects a misunderstanding of the condition.
Choice D rationale
Chemotherapy can affect the immune system, making the client more susceptible to infections and conditions like stomatitis. This statement is accurate and does not indicate a need for further teaching.
Correct Answer is C
Explanation
Choice A rationale
Informing the client that she will need to bring the tick for testing is not necessary. While having the tick can help identify the species and potential risk, it is not required for testing for Lyme disease. The diagnosis can be made based on clinical symptoms and blood tests.
Choice B rationale
Informing the client that the tick is needed to perform a test is incorrect. The presence of the tick is not required for testing for Lyme disease. Blood tests can detect antibodies to the bacteria that cause Lyme disease, even if the tick is not available.
Choice C rationale
Referring the client for a blood test immediately is the appropriate action. Early testing can help diagnose Lyme disease and initiate treatment promptly. Blood tests can detect antibodies to Borrelia burgdorferi, the bacteria that cause Lyme disease, and help confirm the diagnosis.
Choice D rationale
Asking the client about the size and color of the tick is not the most appropriate action. While this information can provide some context, it does not directly contribute to the diagnosis of Lyme disease. The priority is to refer the client for a blood test to confirm the presence of the infection.