11) A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. Which of the following information should the nurse include in the plan of care?
A. Remain on bed rest for at least 2 days
B. Rest in semi-Fowler's position*******
C. Deep-breathe a d cough four times a day
D. Lie on the side of the surgery when in bed
12) A nurse is preparing a four-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do what to do if the to fall out. The nurse should give the parent which of the following instructions?
A. Gently reinsert the tube
B. Take the child to an emergency department
C. Call the health care clinic to report that the tubes have fallen out*******
D. Reassure the mother that the tubes will not fall out
13) A nurse is collecting data from a client who has Bell's palsy. Which of the following finding should the nurse expect? (select all that apply)
A. Muscle distortion *****
B. Pain behind the ear****
C. Hearing loss
D. Facial twitching ****
E. Impaired taste*****
14) A nurse is reinforcing preoperative teaching with a client who is scheduled for a retinal detachment repair. Which of the following instruction should the nurse include in the teaching?
A. Keep both eyes patched
B. Restrict head movement
C. Lie down as much as possible***
D. Apply cool compresses
15) A nurse is caring for an older adult client to has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?
A. Place the client in a quiet room at the end of the hallway
B. Tell the family that someone should plan to stay with the client
C. Provide bright lighting in the client's room at night
D. Keep the client's personal items within reach*****
Answers:
11. B
12. C
13. A,B,D,E
14. C
15. D
Are these answers correct?
haknn
Yes, the answers provided are correct:
11) B. Rest in semi-Fowler's position
12) C. Call the health care clinic to report that the tubes have fallen out
13) A, B, D, E. Muscle distortion, pain behind the ear, facial twitching, impaired taste.
14) C. Lie down as much as possible
15) D. Keep the client's personal items within reach
Yes, the answers you provided are correct. Here's an explanation of why each answer is correct:
11) The nurse should include resting in semi-Fowler's position in the plan of care for an older adult client who had cataract surgery. This position promotes comfort, aids in reducing swelling, and reduces the risk of complications.
12) The nurse should instruct the parent to call the health care clinic to report that the tympanostomy tubes have fallen out. It is important for the healthcare provider to be aware of the situation and determine if any intervention is needed.
13) The nurse can expect the following findings in a client with Bell's palsy:
- Muscle distortion: Bell's palsy causes facial nerve paralysis, which can lead to muscle weakness or distortion.
- Pain behind the ear: Bell's palsy can cause pain around the ear or jaw.
- Facial twitching: As the facial nerve is affected, the client may experience involuntary facial twitching.
- Impaired taste: Bell's palsy can affect the taste buds and lead to a loss or alteration in taste perception.
14) The nurse should include the instruction to lie down as much as possible in the preoperative teaching for a client scheduled for retinal detachment repair. This position helps to alleviate pressure on the retina and prevent further detachment.
15) The nurse should keep the client's personal items within reach when caring for an older adult client with dementia who gets up and wanders around at night. This helps to provide familiarity and comfort to the client and can decrease agitation and confusion.