You are monitoring a child who had a tonsillectomy. On assessment, which findings would indicate to you that the child might be bleeding?
Answer(s): D
Frequent swallowing by the child might indicate that there is bleeding. Other signs or symptoms might include restlessness, vomiting blood, and a fast, thready pulse. Elevation of blood pressure and discomfort do not indicate bleeding.
After a tonsillectomy, your patient begins to vomit. What intervention should be your priority?
Answer(s): B
Your first priority should be to turn the patient on the side to prevent aspiration. Only then should you notify the physician. It is also important to continue to maintain the "nothing by mouth" feeding status of the patient and give antiemetic if prescribed.
When caring for a patient with glaucoma, which of the following symptoms would you not expect to see on the patient's chart?
Frequent pink-eye infections are not symptomatic of glaucoma, but reddening of the eyes is a common sympton.
Which of the following orders would the physician prescribe for the patient with retinal detachment?
Answer(s): C
The physician would order an eye patch to the affected eye. This decreases movement of the eye and prevents further damage to the eye. The physician may limit activity until the eye can be repaired.
What is the accurate procedure for performing a confrontational peripheral vision test?
The examiner and the patient cover the opposite eyes and stare at each other while an object is brought into the line of sight. This test assumes that the examiner has normal vision. The patient indicates when they can see the object. This tests nasal, superior, temporal and inferior visual fields.
Which of the following would the nurse do when performing an otoscopic exam on a patient?
Answer(s): A
The nurse would pull the pinna up and back before inserting the speculum, holding the head slightly away and holding the otoscope upside down like a large pen. The other three options are incorrect.
Your patient is scheduled to go for cataract surgery. What nursing diagnosis should you include in the patients plan of care?
Disturbed sensory perception should be included in this patient's plan of care. The patient's vision would be disturbed related to lens extraction and replacement. The other nursing diagnoses may be appropriate for this patient, but are not relevant to cataract surgery.
What clinical manifestations would you see if your patient had cataracts?
Blurred vision is a clinical manifestation of cataracts. The patient may also exhibit decreased color perception. All other signs are not signs of cataracts.
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