Nokea
The client recently diagnosed with age-related macular degeneration (AMD) in both eyes returns to the clinic for a follow-up appointment. Which assessment will the nurse be certain to include during the visit?
- A. Stools for occult blood
- B. Blood glucose levels
- C. Screening for depression
- D. Screening for hearing loss
Correct Answer: C
Rationale: The nurse should assess for depression because loss of vision can affect functional ability, mood, and quality of life. Depression frequently develops within a few months after AMD is diagnosed in both eyes. GI bleeding, blood glucose, and hearing loss are not directly related to AMD.
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The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data indicate the medication has been effective?
- A. No redness or irritation of the eyes.
- B. A decrease in intraocular pressure.
- C. The pupil reacts briskly to light.
- D. The client denies any type of floaters.
Correct Answer: B
Rationale: Miotic cholinergics (e.g., pilocarpine) reduce intraocular pressure in glaucoma by increasing aqueous outflow. Redness, pupil reaction, and floaters are not primary indicators.
The nurse is concerned that the Caucasian client experiencing a stroke may have impaired hearing. Which observations of the client's behavior prompted this concern? Select all that apply.
- A. Nods and agrees to all statements made by the nurse
- B. Asks for more information about the therapy schedule
- C. Slow to respond verbally but answers questions appropriately
- D. Speaks in an excessively loud tone of voice
- E. Leans in toward the nurse when the nurse speaks
Correct Answer: A,D,E
Rationale: Nodding and agreeing to all statements, speaking loudly, and leaning toward the speaker suggest hearing impairment. Asking for schedule details and slow but appropriate responses do not indicate hearing issues.
The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken?
- A. Encourage him to walk as far as he comfortably can
- B. Suggest that he practice bending and stretching exercises
- C. Walk with him, holding his arm
- D. Tell him to take deep breaths while he is ambulating
Correct Answer: C
Rationale: Walking with the client and holding his arm ensures safety and prevents falls post-stapedectomy.
The client with diminished sight has problems with the glare from light. Which recommendation should the nurse make?
- A. Install fluorescent lighting throughout the home.
- B. Wear sunglasses and hats with brims when outdoors.
- C. Avoid going outdoors on days that are sunny.
- D. Use direct sunlight from windows rather than lights.
Correct Answer: B
Rationale: Wearing sunglasses and hats with brims while outdoors blocks direct light, reducing glare. Fluorescent lighting and direct sunlight increase glare, and avoiding sunny days is unnecessary.
The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching?
- A. I should use magnification devices as much as possible.
- B. I will look at my Amsler grid at least twice a week.
- C. I need to use low-watt light bulbs in my house.
- D. I am going to contact a low-vision center to evaluate my home.
Correct Answer: C
Rationale: Low-watt bulbs reduce visibility, counterproductive in macular degeneration. Magnification, Amsler grid monitoring (daily preferred), and low-vision centers are appropriate.