sensory perception alterations. med surg-unit 8

A nurse is collecting data from a client who has developed a cataract and has come in for a follow up visit. Which of the following statements would indicate to the nurse that the client's condition is worsening?

"I no longer drive when it is dark since I have had problems seeing clearly at night." Clients who are experiencing worsening manifestations of cataracts will experience increasing difficulty with their vision when driving at night, reading books, or looking at computer screen.

A nurse is collecting data from a client related to changes in their vision. Which of the following statements by the client indicates to the nurse that the client may be developing macular degeneration?

"My vision is blurry right in the middle of my eye." This is a statement the nurse would expect from a client developing macular degeneration. Clients experiencing worsening manifestation of macular degeneration will experience diminished central field vision.

A nurse is reinforcing teaching to a group of clients about wet age-related macular degeneration (AMD). Which of the following statements should the nurse include in the teaching?

"Vision changes occur when blood vessels leak fluid or blood under a portion of the retina." Abnormal blood vessels that leak fluid and blood under the macula portion of the retina, causing distorted vision, triggers wet AMD.

A nurse is reinforcing teaching to a group of clients explaining the changes that occur in the eye when clients experience open-angle glaucoma. Which of the following statements should the nurse include in the teaching?

"Vision changes occur when pressure in the eye increases due to a decrease of aqueous humor." Open-angle glaucoma develops slowly over time and progressively causes increased ocular pressure against the optic nerve due to a decrease in the amount of aqueous humor.

A nurse is caring for a client in the clinic. Complete the following sentence by using the lists of options. The nurse suspects the client has developed___ as evidenced by the client's ___ History and Physical​ Past medical history: coronary artery disease, hypertension, beginning stages of renal disease. Atrial fibrillation after stent placed, resolved spontaneously. Past surgical history: Stent to left anterior descending coronary artery 4 years ago.

1. macular degeneration 2. loss of central vision

A nurse is caring for a client in an outpatient surgical area. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Presented to the ED with reports of rapid onset of distorted vision with dark spots floating through their line of vision in the right eye. Denies eye pain but has had nausea since last evening and has not eaten anything since. Client has lifted weights 4 times a week for the last 2 years and states this has not happened before. Anxious. No redness or drainage noted from eye. Denies injury.

Anticipated - Wear sunglasses when near bright sunlight - Administer antibiotic eye drops Nonessential - Do not drive for the next 3 months -Wear eye shield over affected eye at all times Contraindicated - Lie on back when sleeping - May return to previous activities and exercise after one week partual^^^^ In taking action, the nurse should anticipate interventions that will focus on recovery practices that promote reattachment of the retina. Inform the client that following the surgery a protective eye shield will be placed over the affected eye and should be worn nightly for one week. Prescribed eyedrop medications will be administered several times per day and will include antibiotics and anti-inflammatories. Clients may be in an upright position when eating, going to the bathroom, or bathing. Sunglasses should be worn when outdoors or when near bright sunlight. Clients will not be able to drive for approximately two weeks after surgery. To facilitate healing and to decrease the opportunity for retinal displacement during the healing process, clients will be instructed to lie face down for up to three months following surgery. The client should be instructed to refrain from vigorous exercise or activities and no lifting over 15 pounds for approximately three months after the procedure.

A nurse is reinforcing discharge teaching with a client who has macular degeneration. Which of the following lifestyle modifications should the nurse include in the teaching?

Increase daily intake of zinc Clients should increase their daily intake of foods that contain antioxidants, zinc, unsaturated fats, and omega-3 fatty acids.

A nurse is reinforcing teaching to a client who is experiencing tinnitus about medications that should be avoided. Which of the following medications should the nurse include in the teaching?

Furosemide Diuretics, like furosemide, can become ototoxic. Clients experiencing tinnitus should avoid this taking medication.

A nurse is caring for a client in a clinic. For each assessment finding, click to specify if the finding is consistent with glaucoma, cataract, or retinal detachment. Each finding may support more than 1 disease process. 7 years ago: Presents to the clinic after being splashed in the face with vinegar, causing reddening of the eye and pain. States vision is hazy. Eye flushed with 10 mL of 0.9% normal saline. Eye exam completed. PERRLA. Visual acuity 40/20 affected eye, 20/20 unaffected eye. IOP 15 mm Hg. Discharged home with Tobramycin 0.3% ophthalmic solution 2 drops every 4 hour x 48 hours and then 2 drops every 6 hours for 5 days. Follow-up in 3 days.

Glaucoma' - hazy vision - difficulty seeing at night - hypertension - history of eye injury Cataract - double vision - hazy vision - difficulty seeing at night - hypertension - history of eye injury Retinal Detachment - hazy vision - hypertension CORRECT When analyzing cues, the nurse should recognize that manifestations of glaucoma include hazy vision, difficulty seeing at night, hypertension, and a history of eye injury. Manifestations of cataracts include double vision, hazy vision, difficulty seeing at night, hypertension, and a history of eye injury. Manifestations of retinal detachment include hazy vision and hypertension.

A nurse caring for a client who has had a cochlear implant insertion. Which of the following interventions should the nurse perform to prevent increasing the client's intracranial pressure?

Position the client on their side with operative ear facing up. This is the correct post-operative intervention for a client after cochlear implant insertion. To prevent increasing intracranial pressure, the client should lie on the unaffected side when sleeping.

A nurse is developing a plan of care for a client with Meniere's Disease. Which of the following lifestyle modification should the nurse include in the plan of care?

Practice deep breathing techniques Stress can intensify the symptoms, so it is essential to provide the client and caregivers with information on methods to reduce stress (meditation, relaxation breathing/deep breathing, exercise).

A nurse is preparing to collect visual acuity data from a client with a cataract in the right eye. The nurse should anticipate using which of the following tools for this task?

Snellen chart The nurse would use a Snellen chart to assess visual acuity or sharpness of vision.

A nurse is reinforcing teaching to a client on the proper care of hearing aids. Which of the following should the nurse include in the teaching?

Use a wax pick to remove hearing aid debris. Regularly removing debris is a method that should be included in the proper care of hearing aids. The wax pick will gently remove accumulated ear wax or other debris.