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The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Check the client’s hemoglobin A1c.
- C. Assess the client’s vision using the Amsler grid.
- D. Teach the client about controlling blood glucose levels.
- E. Determine where the spots appear to be in the client’s field of vision.
Correct Answer: A,E,C,B,D
Rationale: 1) Notify HCP (urgent for possible diabetic retinopathy); 2) Determine spot location (assess severity); 3) Amsler grid (evaluate central vision); 4) Check HbA1c (assess control); 5) Teach glucose control (long-term management).
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The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from a cataract. Which question will help determine whether a cataract is developing?
- A. Has your ability to perceive colors changed?
- B. Does your vision appear distorted or wavy?
- C. Does the center of your visual field appear dark?
- D. Do you see random flashes of bright light?
Correct Answer: A
Rationale: Asking about a change in the ability to perceive colors will help in determining cataract development. Cataract formation involves the lens of the eye becoming more opaque, thus decreasing the vibrancy of colors. Distorted central vision is a sign of macular degeneration. A darkened area in the center of the visual field is associated with macular degeneration. Seeing flashes of bright lights is associated with retinal detachment.
The client has a hearing loss from a possible acoustic neuroma. The nurse should prepare the client for which diagnostic test to confirm the presence of a tumor?
- A. Tympanometry
- B. Arteriogram of the cranial vessels
- C. Magnetic resonance imaging (MRI)
- D. Auditory canal biopsy
Correct Answer: C
Rationale: MRI with gadolinium enhancement is the most reliable test in determining size and anatomical location of an acoustic neuroma. Tympanometry, arteriogram, and biopsy are not used for this diagnosis.
A resident of a long-term care facility tells the nurse, 'I'm having a hard time hearing people talk and can't understand the voices on TV.' Which action is most appropriate?
- A. Teach the client about eliminating background noises in the room.
- B. Assess the client's hearing and use an otoscope for examination.
- C. Schedule an appointment with the HCP for bilateral ear irrigations.
- D. Instruct the client to look at the speaker's lips to decipher words.
Correct Answer: B
Rationale: The nurse should assess the client's hearing and perform an otoscopic examination to verify symptoms and identify the cause. Other actions follow assessment.
The client's eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye and 20/30 in the left eye. How should the nurse interpret these results?
- A. The client has elevated intraocular pressure in both eyes.
- B. The client needs testing for glaucoma with a tonometer.
- C. The left eye is closer to normal vision than the right eye.
- D. The client has errors of refraction indicating astigmatism.
Correct Answer: C
Rationale: The Snellen chart is used to test distance vision. The numbers recorded indicate that at 20 feet (the first number) the client is able to read what a person with normal vision can read at another distance (second number). The left eye's vision recorded as 20/30 has better vision than the right eye with vision recorded as 20/40. The Snellen chart is not used to measure intraocular pressure, suggest glaucoma testing, or determine astigmatism.
The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?
- A. Elderly clients react to pain the same way any other age group does.
- B. The elderly client usually requires more pain medication.
- C. Reaction to painful stimuli may be decreased with age.
- D. The elderly client should use the Wong scale to assess pain.
Correct Answer: C
Rationale: Age-related sensory decline reduces pain perception in the elderly, affecting reporting. Pain reaction varies, more medication is not standard, and the Wong scale is pediatric.