Nokea
At morning report, the nurse learns the assigned client is blind. Which question should the nurse ask the client upon initial assessment?
- A. Have you always been blind?
- B. What caused your vision problem?
- C. Are you dependent with your care?
- D. Can you perceive light and motion?
Correct Answer: D
Rationale: Many people who are considered blind perceive light and motion. Establishing this fact can help in developing a plan of care for this client. Establishing cause and length of time for visual impairment is not required for initial care. Asking the client about dependence is important, but the new environment could provide safety issues (even if independent) if no perception of light is identified.
You may also like to solve these questions
A middle-aged client reports increasing difficulty reading newspaper print. Which of the following nursing explanations best describes this type of refractive error?
- A. Client is nearsighted.
- B. Lens has become cloudy and thick.
- C. Loss of elasticity of the lens.
- D. Floaters in the eye increase with age.
Correct Answer: C
Rationale: Presbyopia is a result of poor accommodation due to a loss of elasticity of the ciliary muscles and lens. Nearsighted refers to myopia. Cloudiness of lens is also associated with the aging process and does interfere with vision as a result of cataract formation. Floaters in the eyes are more apparent with aging but appear as dark spots.
A nurse is caring for a client who has undergone enucleation. What complication of enucleation should be addressed by the nurse?
- A. Hypotension
- B. Nausea and vomiting
- C. Hemorrhage
- D. Pneumonia
Correct Answer: C
Rationale: The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting are common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.
A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client?
- A. Patchy flakes clinging to the eyelashes
- B. A red pustule in the internal tissue of the eyelid
- C. Redness surrounding the conjunctival sac
- D. A halo around the pupil
Correct Answer: A
Rationale: Blepharitis is an inflammation of the lid margins. The nurse monitors visible patchy flakes clinging to the eyelashes and about the lids. The condition does not cause redness or a halo around the pupil. In case of a sty, the nurse would observe a red pustule in the internal tissue of the eyelid.
A nurse is caring for a client who has just been diagnosed with glaucoma. What teaching should the nurse include with this client?
- A. How long it will be necessary to wear dark glasses
- B. The importance of regular bowel habits
- C. What vegetables to eat
- D. When it will be possible to read again
Correct Answer: B
Rationale: Instructions for the client with glaucoma include the following: Obtain assistance from a family member, relative, or friend if having trouble instilling eye drops. Avoid all drugs that contain atropine. Check with physician or pharmacist before using any nonprescription drug. preparations for cold or allergy symptoms may contain an atropine-like drug. Maintain regular bowel habits; straining at stool can raise intraocular pressure (IOP). Avoid heavy lifting and emotional upsets (especially crying) because they increase IOP. Patients do not have to wear dark glasses. Vegetable consumption is not restricted. Reading does not increase IOP.
A nurse is caring for an older adult client with macular degeneration who has received injections of angiogenesis inhibitors. Which assessment finding would indicate the condition is worsening?
- A. Blurred vision
- B. Burning sensation of the eyes
- C. Loss of peripheral field vision
- D. Central vision impairment
Correct Answer: D
Rationale: When the macula becomes irreparably damaged, central vision is lost and the client can only see images via peripheral field. Blurred vision is the initial symptom of the disease and does not signify worsening. Burning sensation is a common adverse reaction to the treatment injection.