Nokea
The client with macular degeneration is told the condition is progressing to an advanced stage. Which findings should the nurse expect when completing the assessment? Select all that apply.
- A. Curtain appearance over part of the visual field
- B. Loss of peripheral vision in the affected eye
- C. Difficulty seeing in dimly lit environments
- D. Visual distortions in the central vision
- E. Clouding of the lens in both eyes
Correct Answer: C,D
Rationale: Difficulty seeing in dimly lit environments is from the slow breakdown of the outer layer of the retina and the formation of drusen within the macula. The macula is the area of central vision, and with macular degeneration, there is the loss or distortion of central vision. Curtain appearance is associated with retinal detachment, peripheral vision loss with glaucoma, and clouding of the lens with cataracts.
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An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss?
- A. Place frequently used items on the affected side
- B. Position her so that her affected side is toward the activity in the room
- C. Encourage her to turn her head from side to side to scan the environment on the affected side
- D. Stand on the affected side while assisting her in ambulating
Correct Answer: C
Rationale: Encouraging head turning to scan the environment compensates for right homonymous hemianopia by ensuring awareness of the affected side.
Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma?
- A. Incapacitating vertigo and otorrhea.
- B. Nystagmus and complaints of dizziness.
- C. Nausea and vomiting.
- D. Unilateral hearing loss and tinnitus.
Correct Answer: D
Rationale: Acoustic neuroma (vestibular schwannoma) causes unilateral hearing loss and tinnitus due to cranial nerve VIII compression. Vertigo, nystagmus, and nausea are less prominent; otorrhea is unrelated.
Which of the following would not be included in the nursing care plan for a client with Parkinson's disease?
- A. Restricting his intake of oral fluids
- B. Range of motion exercises
- C. Allowing him to carry out activities of daily living by himself even though he is very slow
- D. Providing him with diversionary tasks that require motor coordination of hands
Correct Answer: A
Rationale: Fluids should be encouraged to prevent dehydration and manage drooling in Parkinson's disease, making restriction inappropriate.
The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?
- A. Ensure the client's room temperature is cool.
- B. Talk louder to make sure the client hears clearly.
- C. Complete the admission as fast as possible.
- D. Provide extra orientation to the surroundings.
Correct Answer: D
Rationale: Extra orientation helps elderly clients with sensory deficits adjust to new environments, enhancing safety. Cool rooms, loud talking, and rushed admissions are less effective.
The nurse is examining the client's ear using an otoscope and sees the image illustrated. Which documentation by the nurse is best?
- A. Tympanic membrane ruptured, no excessive cerumen
- B. External ear canal showing no lesions or drainage
- C. Tympanic membrane cone of light reflex distorted
- D. Bony landmarks prominent on tympanic membrane
Correct Answer: C
Rationale: The tympanic membrane shown is reddened, and the cone of light is distorted, indicating increased pressure behind the tympanic membrane. The membrane is intact, the external canal is not shown, and bony landmarks are not prominent.