The cookie settings on this website are set to 'allow all cookies' to give you the very best experience. Please click Accept Cookies to continue to use the site.

Solution manual for Prioritization, Delegation, and Assignment- Practice Exercises for the NCLEX Examination, 3rd Edition by Linda A. LaCharity, Candice K. Kumagai, Barbara Bartz

$35.00
(No reviews yet) Write a Review
SKU:
Solution manual for Prioritization, Delegation, and Assignment- Practice Exercises for the NCLEX Examination, 3rd Edition by Linda A. LaCharity, Candice K. Kumagai, Barbara Bartz
Availability:
Solution manual for Prioritization, Delegation, and Assignment- Practice Exercises for the NCLEX Examination, 3rd Edition by Linda A. LaCharity, Candice K. Kumagai, Barbara Bartz

Description

 
 
 

Answer Key

 

CHAPTER 10: Visual and Auditory Problems,

pages 49-52

  1. Ans: 3 If the client is wearing contact lenses, the lenses may be causing the symptoms, and removing them will prevent further eye irritation or damage. Policies on giving telephone advice vary among in- stitutions, and knowledge of your facility policy is essential. The other options may be appropriate, but you should gather additional information before sug- gesting anything else. Focus: Prioritization; QSEN: S; Concept: Clinical Judgment
  2. Ans: 3 Most accidental eye injuries (90%) could be prevented by wearing protective eyewear for sports and hazardous work. Other options should be consid- ered in the overall prevention of injuries, but these have less impact. Focus: Prioritization; QSEN: S; Concept: Patient Education
  3. Ans: 1, 3, 5, 6 Providing postoperative and preop- erative instructions, making home health referrals, and assessing for needs related to loss of vision should be done by an experienced nurse who can give specific details and specialized information about follow-up eye care and adjustment to loss. The principles of applying an eye pad and shield and teaching the administration of eyedrops are basic procedures that should be familiar to all nurses. Focus: Assignment; QSEN: TC; Concept: Clinical Judgment
  4. Ans: 6, 2, 5, 4, 3, 1 Have the client sit with the head tilted back. Pulling down the lower conjunctival sac creates a small pocket for the drops. Stabilizing the hand prevents accidentally poking the client’s eye. Having the client look up prevents the drops from falling on the cornea and stimulating the blink reflex. When the client gently moves the eye, the medication is distributed. Pressing on the lacrimal duct prevents systemic absorption. Focus: Prioritization; QSEN: N/A; Concept: Clinical Judgment
  5. Ans: 2, 3, 4, 7 Administering medications, review- ing and demonstrating standard procedures, and per- forming standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. Focus: Delegation; QSEN: TC; Concept: Clinical Judgment

6. Ans: 2 Try to find out how much and how fre- quently she has been taking the drops by mouth. This information will be needed if you call the oph- thalmologist for an order or if you call Poison Con- trol. A good follow-up question is to try to find out why she is taking the drops by mouth. She may be very confused, or there may have been an error of omission in client education by all health care team members who were involved in the initial prescrip- tion. Focus: Prioritization; QSEN: S; Concept: Clinical Judgment

7. Ans: 1 Warm compresses will usually provide relief. If the problem persists, eyelid scrubs and antibiotic drops would be appropriate. The ophthalmologist could be consulted, but other providers such as the family physician or the nurse practitioner could give a prescription for antibiotics. Focus: Prioritization; QSEN: N/A; Concept: Clinical Judgment

8. Ans: 4 A curtainlike shadow is a symptom of retinal detachment, which is an emergency situation. A change in color vision is a symptom of cataract. Crusty drainage is associated with conjunctivitis. Increased lacrimation is associated with many eye irritants, such as allergies, contact lenses, or foreign bodies. Focus: Prioritization; QSEN: S; Concept: Clinical Judgment

9. Ans: 2, 5 Assisting the client with ambulating in the hall and obtaining supplies are within the scope of practice of the UAP. Counseling for emotional problems, orienting the client to the room, and en- couraging independence require formative evaluation to gauge readiness, and these activities should be the responsibility of the RN. Storing items and rearrang- ing furniture are inappropriate actions, because the client needs be able to consistently locate objects in the immediate environment. Focus: Delegation; QSEN: TC; Concept: Functional Ability

10. Ans: 4 Pain may signal hemorrhage, infection, or increased ocular pressure. A scratchy sensation and loss of depth perception with the patch in place are not uncommon. Adequate vision may not return for 24 hours. Focus: Prioritization; QSEN: S; Concept: Patient Education

11. Ans: 3, 4, 5, 6 The client’s symptoms are suggestive of angle-closure glaucoma. Immediate inventions include instillation of miotics, which open the tra- becular network and facilitate aqueous outflow, and

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

e1

e2

intravenous or oral administration of hyperosmotic agents to move fluid from the intracellular space to the extracellular space. Applying cool compresses and providing a dark, quiet space are appropriate comfort measures. Photodynamic therapy is a treatment for age-related macular degeneration. Use of mydriatics is contraindicated because dilation of the pupil will further block the outflow. Focus: Prioritization; QSEN: S; Concept: Clinical Judgment

12. Ans: 4 All beta-adrenergic blockers are contraindi- cated in bradycardia. Alpha-adrenergic agents can cause tachycardia and hypertension. Carbonic anhy- drase inhibitors should not be given to clients with rheumatoid arthritis who are taking high dosages of aspirin. Focus: Prioritization; QSEN: S; Concept: Clinical Judgment

13. Ans: 2 Asking the nurse to explain the documenta- tion is a way of assessing her knowledge of documen- tation, how the client’s complaint contributes to what should be assessed, and her understanding of the use of abbreviations. The nurse may have a good reason for charting “N/A,” but you should explain how a reader could misunderstand. For example, “visual acuity N/A” could be interpreted as the nurse making a clinical judgment that assessing vision was not important for this client. The documentation is not acceptable, because the client’s chief complaint indicates that vision should be tested if at all possible. Redoing the assessment yourself does not help the nurse to correct mistakes. Contacting the educator for assistance is an option that is based on your assessment of her ratio- nale. Focus: Supervision, prioritization; QSEN: TC, QI; Concept: Communication

14. Ans: 1, 2, 3 Irrigating the ear, giving medication, and reminding the client about postoperative instruc- tions that were given by an RN are within the scope of practice of the LPN/LVN. Counseling clients and families and assessing for meningitis signs in a client with labyrinthitis are the responsibilities of the RN. Focus: Delegation; QSEN: TC; Concept: Clinical Judgment

15. Ans: 1, 2, 3, 4 Medications such as aspirin or di- uretics (and many others) can cause tinnitus (ringing in the ears). Loud noises, impacted earwax or foreign bodies in the ear canal, or ear infections can also cause tinnitus. Asking about frequency of hygiene is less relevant than asking about the method the client uses to clean the ears. For example, the insertion of cotton-tipped swabs may be contributing to the

impaction of earwax. Focus: Prioritization; QSEN:

N/A; Concept: Clinical Judgment
16. Ans: 2 This client has a hearing loss, and it seems

likely that a referral for a hearing aid or rehabilitation program will allow her to participate in her baseline social habits. The other diagnoses are pertinent if the hearing loss continues to interfere with her quality of life. Focus: Prioritization; QSEN: PCC; Concept: Functional Ability

17. Ans: 3 A bulging red or blue tympanic membrane is a possible sign of otitis media or perforation. The other signs are considered normal anatomy. Focus: Prioriti- zation; QSEN: EBP; Concept: Clinical Judgment

18. Ans: 3 The client reporting vertigo without hearing loss should be further assessed for nonvestibular causes, such as cardiovascular or metabolic. The other descriptions are more commonly associated with in- ner ear or labyrinthine causes. Focus: Prioritization; QSEN: S; Concept: Clinical Judgment

19. Ans: 1. MD, 2. UAP, 3. LPN/LVN or RN, 4. MD, 5. RN, 6. Physical therapist The physician is re- sponsible for determining the medical diagnosis and for explaining the outcomes and risks of surgical procedures. A physical therapist evaluates movement and the need for adaptive equipment and teaches ambulation techniques; however, the UAP (under supervision) is able to help clients with routine am- bulation and position changes. The LPN/LVN and RN are qualified to give medications. The RN should assess the client to identify situations associated with vertigo. Focus: Assignment; QSEN: TC; Con- cept: Clinical Judgment

20. Ans: 3 Heavy lifting should be strictly avoided for at least 3 weeks after stapedectomy. Water in the ear and air travel should be avoided for at least 1 week. Coughing and sneezing should be performed with the mouth open to prevent increased pressure in the ear. Focus: Prioritization; QSEN: S; Concept: Patient Education

21. Ans: 1, 5, 2, 7, 3, 4, 6 Use an otoscope to assess the ear first and then fill the syringe with warm fluid. Angle the syringe to allow the fluid to flow along the side of the ear canal, not directly at the eardrum. Flush with continuous pressure, rather than a pumping action. You should see fluid return with cerumen. If not, then wait at least 10 minutes and repeat. Tipping the head allows gravity drainage of fluid left in the ear canal. Focus: Prioritization; QSEN: N/A; Concept: Clinical Judgment

 
 

QSEN Key: PCC, Patient-Centered Care; TC, Teamwork & Collaboration; EBP, Evidence-Based Practice; QI, Quality Improvement; S, Safety; I, Informatics Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Answer Key