Nursing 2 Sensory Perception
How is AMD defined?
Age related degeneration of the retina involving the macula that is characterized by loss of central vision, presence of drusen, and atrophy of the macular retinal pigment.
What are the clinical manifestations of hypercalcemia?
Lethargy, nausea, vomiting, paresthesias, and personality changes.
What are the clinical manifestations of hyponatremia?
Nausea, malaise, and changes in mental status.
What are the neurologic manifestations of hyperthyroidism?
Blurred vision, Exophthalmos. Blurred vision and exophthalmos are the neurological manifestations of hyperthyroidism. Fatigue is the metabolic manifestation of hyperthyroidism. Diaphoresis, or excessive sweating, is the skin manifestation of hyperthyroidism. Shallow respirations are the cardiopulmonary manifestation of hyperthyroidism.
A client has a diagnosis of myasthenia gravis. What does the nurse recall are associated clinical manifestations?
Blurred vision along with episodes of vertigo. Blurred vision and episodes of vertigo are symptoms of myasthenia gravis and are aggravated by physical activity. Intentional tremors are associated with multiple sclerosis. Exercise decreases muscle strength. The proximal muscles are more involved than the distal muscles.
What is the difference between dry AMD and wet AMD?
Dry AMD has no cure and management is focused on slowing disease progression. Wet or exudative AMD may be slowed or stopped with medications, PDT, or laser therapy.
How is the patellar reflex elicited?
Striking the patellar tendon just below the patella.
While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? A. 29 C B. 33 C C. 36 C D. 38 C
33 C. A body temperature in the range of 36° to 38 ° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hyperthermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.
The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. A. Apraxia B. Aphasia C. Agnosia D. Amnesia
Agnosia. Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.
The nurse is providing home care education to a client who underwent cataract surgery. Which information should the nurse include? Sleep on operative side. Expect eye pain, headaches, and redness of the affected eye. Remove eye dressing at night. Avoid strenuous exercise.
Avoid strenuous exercise. The nurse should educate the client about the importance of avoiding strenuous exercise. The client needs to sleep on the nonoperative side, not the operative side. The client should not disturb the eye dressing. Eye pain, headaches, and redness of the affected eye are manifestations of complications and should be reported to the healthcare provider immediately.
A client underwent an external ear assessment and is diagnosed with hard nodules on the pinna. Which assessment finding indicates tophi?
Increased uric acid levels in the blood. Chronic gout is characterized by hard, irregular, painless nodules on the pinna or external ear known as tophi that form due to the accumulation of uric acid crystals. This condition is diagnosed by increased levels of uric acid in the blood. Squamous cell carcinoma is diagnosed by the appearance of small, crusted, ulcerated, or indurated lesions on the pinna that fail to heal.
What clinical indicators should the nurse expect when interviewing and assessing a client with Meniere disease?
Nausea, Dizziness, Jerky lateral eye movements. Nausea is related to vertigo, which is associated with this disorder. The sensation of spinning (vertigo) occurs with inflammation of the inner ear. Jerky lateral eye movement (nystagmus), particularly toward the involved ear, occurs with Meniere disease. The heart rate does not decrease with this disorder. Body temperature is not influenced by this disorder.
Which client eye movement does the superior oblique muscle control?
Pulls the eye downward. The superior oblique muscle contracts alone and pulls the eye downward. The inferior oblique muscle helps in pulling the eye upwards. The medial rectus muscle contracts alone and turns the eye towards the nose. The lateral rectus muscle turns the eye towards the side of the head.
A client is diagnosed as having expressive aphasia. Which type of impairment does the nurse expect the client to exhibit?
Speaking or writing. Damage to the Broca area, located in the posterior frontal region of the dominant hemisphere, causes problems in the motor aspect of speech, like speaking and writing. Impairments such as following specific instructions, understanding speech or writing, and recognizing words for familiar objects are associated with receptive aphasia, not expressive aphasia; receptive aphasia is associated with disease of the Wernicke area of the brain.
The parents of a newborn who is undergoing phototherapy ask the nurse why their baby's eyes are covered with eye patches. Which information is important for the nurse to remember before responding?
They prevent injury to the conjunctiva and retina. Eye patches are applied while an infant is undergoing phototherapy to prevent drying of the conjunctiva, injury to the retina, and alterations in biorhythms. The infant will close the eyes automatically in response to bright lights and application of a patch. The infant should be exposed to bright lights periodically so circadian rhythms will become established. Rapid eye movements are automatic during different phases of sleep and will not be affected by eye patches.
John Gleason presents to his healthcare provider complaining of blurred vision and seeing flashes of light for the past several hours. Based on these symptoms, which diagnostic test do you anticipate for this client? Facial x-ray CT scan Ultrasonography Visual acuity test
Ultrasonography. Based on these symptoms, the client requires a diagnostic test to confirm a detached retina. Ultrasonography is used to diagnose this condition. Visual acuitytest, facial x-ray, and a CT scan are not.
A healthcare provider recently made the diagnosis that a client has glaucoma. The nurse is preparing to administer eyedrops to the client. Which ophthalmic solution is contraindicated for this client?
Atropine. Atropine, a mydriatic ophthalmic solution, is contraindicated for clients with glaucoma because it dilates the pupil, increasing intraocular pressure. Timolol, a beta blocker, decreases aqueous humor production; beta blockers are the preferred initial medications given to reduce intraocular pressure. Pilocarpine, a cholinergic, constricts the pupil, thereby increasing aqueous humor outflow. Epinephrine, an adrenergic agent, enhances aqueous humor outflow, thereby reducing intraocular pressure.
A client goes to a healthcare clinic for possible cataracts. When completing a physical examination of the eye, which manifestation will assist in making a diagnosis of cataracts? Colored halos around lights Cloudy vision or halos Blurred central vision Intact peripheral vision
Cloudy vision or halos. Cloudy vision or halos are a manifestation of cataracts. Intact peripheral vision and blurred central vision are manifestations of macular degeneration, not cataracts. Colored halos around lights are not a clinical manifestation of cataracts.
A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit?
Cool skin, Constipation, Periorbital edema, Decreased appetite. Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edemas are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. Photophobia is associated with exophthalmos that occurs with hyperthyroidism.
After receiving streptomycin sulfate for 2 weeks as part of the medical regimen for tuberculosis, the client states, "I feel dizzy and I can't hear as well as usual." The nurse withholds the drug and promptly reports the problem to the healthcare provider. Which part of the body does the nurse determine is being affected as indicated by the symptom reported by the client?
Eighth cranial nerve's vestibular branch. Streptomycin sulfate is ototoxic and may cause damage to auditory and vestibular portions of the eighth cranial nerve. Pyramidal tracts, cerebellar tissue, and peripheral motor end-plates are not affected by streptomycin.
A client with a history of stabbing pain in the eyes and blurring and gradual loss of vision is examined by an ophthalmologist, a neurologist, and an internist, all of whom find no organic cause. When eye complaints increase, the client is admitted to a mental health unit. What is the priority nursing intervention?
Focusing on daily activities while avoiding discussion of the eye discomfort. The client's eye problems are a conversion reaction. Avoiding discussion of the physical problems prevents the client from using this topic to avoid an exploration of feelings. Focusing on the safe topic of activities may eventually progress to a discussion of emotion-laden topics such as feelings. It is too early for encouraging involvement in group activities; the client is too introspective to become involved with group activities at this time. Focusing on the physical problem allows the client to avoid feelings. The data do not indicate that the client has an organic problem and is going blind.
Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?
Increasing intracranial pressure. Increased intracranial pressure compresses vital brain tissue; this is manifested by a sluggish pupillary response and an increased systolic blood pressure. Spinal shock is manifested by decreased systolic blood pressure, with no pupillary changes. Hypovolemic shock is indicated by decreased systolic pressure and tachycardia, with no changes in pupillary reaction. Transtentorial herniation is manifested by dilated pupils and severe posturing.
Mr. Leonard is an older African American man who has been diagnosed as having bilateral cataracts. He has experienced decreased visual acuity and an increase in glare over the past year. He had the right cataract removed and a lens implant performed today, and you are reviewing his discharge instructions with him. When you discuss the need for a stool softener to reduce straining while stooling, he is confused and asks why this pill is needed. Which is your best response to Mr. Leonard's question? "Straining when having a bowel movement may result in nausea and vomiting." "This pill will act as a laxative and reduce the risk of constipation, which may occur as side effects of other medications." "Blood vessels in your eye may burst when defecating, causing intraocular hemorrhage and potential blindness." "Pressure builds up in your eye and could cause problems with the surgical repair of your right eye if you strain when having a bowel movement."
"Pressure builds up in your eye and could cause problems with the surgical repair of your right eye if you strain when having a bowel movement."Addressing the connection between straining when having a bowel movement and increasing pressure in the eye, as well as the desire for a positive, expected surgical outcome, enhances compliance with taking the medication. Stating the action of the medication in simple terms increases the likelihood of compliance. The stool softener is not a laxative. Using strong terms with medical implications, such as "intraocular pressure," "intraocular hemorrhage," and "potential blindness," which may not be understood by the client, may instill fear or disregard for the instructions. Although there is a correlation between actions that increase intraocular and intracranial pressure, increased intracranial pressure is not of concern to this client and serves to confuse the instructions.
The nurse is visiting the home of Aida Johanson, an 85-year-old client newly diagnosed with open-angle glaucoma. What information should the nurse provide to Mrs. Johanson about home safety? "The furniture should not be moved or rearranged." "The library might have books with large print so that you can continue to read." "The eye medication must be used as prescribed." "There are local transportation companies available so that you can arrive safely to your scheduled appointments."
"The furniture should not be moved or rearranged." For the client with impaired vision, it can be difficult to adapt to changes in theenvironment, so maintaining the same position of belongings is important for client safety. Large-print books, transportation, and medication compliance are not directly related to home safety.
What medications are used to treat wet AMD?
ranibizumab (Lucentis), bevacizumab (Avastin), aflibercept (Eylea), and pegaptanib (Macugen) are selective endothelial growth factor inhibitors that are injected into the vitreous cavity to slow vision loss in wet AMD.
The primary healthcare provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question is priority that the nurse should ask the client?
"Do you take antidepressants?" Clients prescribed adrenergic agonists should be asked whether they are taking any antidepressants, such as phenezeline, because these medications increase blood pressure as do the adrenergic agonists; hence, this may lead to a hypertensive crisis. Clients prescribed beta-adrenergic blockers should be asked about any respiratory disorders, such as asthma, because the drug causes constriction of pulmonary smooth muscle which may lead to narrowing of the airway. Carbonic anhydrase inhibitors are similar to sulfonamides. Therefore, they should not be prescribed to clients who are allergic to sulfonamides. While asking about contact lensesis appropriate, this is not the priority for adrenergic agonist; discoloration of lens is not a critical as hypertensive crisis
How is the brachioradialis reflex elicited?
By striking the radius 3 to 5 cm above the wrist. The brachioradialis reflex can be elicited by striking the radius 3 to 5 cm above the wrist while the client's arm is relaxed. Striking the triceps tendon above the elbow elicits the triceps reflex.
While assessing an older adult with decreased perception of touch, the nurse provides instructions to the client to reduce the risk associated with falling. Which statements made by the nurse are beneficial to the client?
"Look where your feet are placed while walking." "Wear shoes that give good support while walking." "If you are unable to change your position frequently request assistance." Decreased perception of touch is a physiological change of the nervous system associated with aging. The client may experience decreased sensory perception that may cause the client to fall. The client should be instructed to look carefully where feet are placed while walking to prevent falling. Good support from wearing shoes while walking may reduce the risk of falling in clients with decreased perception of touch. If the client is unable, the caretaker should change the position of the client frequently (every hour) while the client is in bed or in a chair. Physiological changes, such as altered balance and decreased coordination, may lead to a fall if the client is moving quickly. The client with this neurological change should move slowly when changing positions and hold on to handrails while walking to prevent falls.
A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." What is the nurse's best response?
"The medication may need to be discontinued. Come to the clinic this afternoon." Yellow vision indicates digoxin toxicity; the medication should be withheld until the healthcare provider can assess the client and check the digoxin blood level. Yellow vision is related to digoxin therapy, not the client's underlying medical condition. Yellow vision is a sign of digoxin toxicity; taking more digoxin will escalate the digoxin toxicity.
An inadequately immunized 4-year-old client who was injured recently is found to have tetanus and admitted to the pediatric intensive care unit. The parents ask to assist with their daughter's care. What is the best response by the nurse?
"Your desire to help is understandable, but we have to avoid excessive stimuli." The nurse is empathizing with the parents while giving an honest appraisal of the child's needs. Unnecessary auditory or visual stimuli may cause muscle spasms and should be avoided. Any stimulus may precipitate muscle spasms; the statement "You may talk to her, but don't touch her, because it could cause a seizure" may increase the parents' anxiety. Although parental concern is acknowledged when the nurse expresses understanding, the question is not answered.
A male client who sustained a head injury is admitted to the hospital. The client is able to open his eyes to pain stimulus and to localize the pain, but the verbal response is found to be confused. What would be the score of the client based on the Glasgow coma scale.
11. Because the client opens his eye to pain stimulus, is able to localize the pain, and has a confused verbal response, the client's score is 2+5+4=11. The Glasgow coma scale is used to establish baseline data in eye opening, motor response, and verbal response in acute care settings. According to the Glasgow coma scale:Eye opening: spontaneous-4, to sound-3, to pain-2, never-1.Motor answer: obeys commands-6, localizes pain-5, normal flexion (withdrawal) -4, abnormal flexion-3, extension-2, none-1.Verbal answer: oriented-5, confused conversation-4, inappropriate words-3, incomprehensible sounds-2, none-1.
The nurse is preparing to administer ear drops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications?
Allergy to the medication, Drainage from the ear canal, Tympanic membrane rupture. Contraindications to ear drops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Itching may occur with some ear conditions and is not a contraindication to the use of ear drops. Partial hearing loss may occur with impacted cerumen and is not a contraindication to the use of ear drops.
The nurse is identifying diagnoses appropriate for a client with glaucoma. Which diagnosis should the nurse identify as lowest priority for this client's care? Self-care deficit Risk for injury Anxiety Altered nutrition
Altered nutrition. Risk for injury, anxiety, and self-care deficit are all common nursing diagnoses for a client with glaucoma. Risk for altered nutrition has the lowest priority for this client.
A nurse is teaching the parents of an 18-month-old child the procedure for instilling ear drops. How should this procedure be done?
By pulling the pinna down and back to straighten the auditory canal before instillation of the drops. The canal curves upward in children younger than 3 years of age; pulling the pinna down straightens the canal so medication will reach the eardrum. The ear canal is not cleansed before ear drops are instilled; this could exacerbate the infection. Applying ear wicks is contraindicated because it increases pressure within the ear. Pulling the pinna up and back after instillation of drops is unnecessary; pressing on the tragus several times will help disperse the drops.
Which physiologic responses should a nurse expect when assessing a client with hyperthyroidism?
Blurred vision, Increased appetite, Widened pulse pressure. Blurred vision may occur as a result of exophthalmos. The appetite increases in an attempt to meet the caloric needs of the body. As the systolic pressure increases, it causes a widened pulse pressure (the difference between the systolic and diastolic blood pressures). Tachycardia, not bradycardia, occurs because of the increased metabolic rate. Intolerance to heat, not cold, occurs because of the increased metabolic rate.
A client with glaucoma asks a nurse about future treatment and precautions. Which information should the nurse's explanation include?
Continuation of therapy for life. Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. Cholinergics are used in the treatment of glaucoma; anticholinergics are contraindicated. The surgical replacement of lens is the treatment for cataracts. There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected.
A client with a parotid tumor that involves the lymph glands in the neck is prescribed vincristine, cyclophosphamide, and prednisone. The nurse should monitor the client for what adverse effect?
Peripheral paresthesia. Peripheral paresthesia is an indication of toxicity from a plant alkaloid such as vincristine. Anginal-type chest pain, ophthalmic papilledema, and bilateral crackles in the lung are not side effects of any of the drugs listed.
The nurse frequently provides care for clients with hearing aids. Which condition does the nurse recall responds best to hearing aids?
Diminished sensitivity of the cochlea. Because hearing aids use the person's own middle ear, they increase hearing acuity in cases of diminished sensitivity of the cochlea; the amplified signal from the hearing aid gives the cochlea greater stimulation and promotes hearing. Destruction of the auditory nerve results in deafness because impulses cannot be transmitted to the brain's auditory center. Perforation of the tympanic membrane prevents ossicular conduction, which involves transmission of resonant vibrations from the tympanic membrane to the ossicles to the cochlea. Hearing aids will not correct this type of hearing loss; surgery is preferred. Immobilization of the ossicles prevents conduction of resonant vibrations from the tympanic membrane to the cochlea. Hearing aids may help but will not correct this problem; surgery is preferred.
A nurse in the emergency department admits a client who was involved in a motor vehicle crash with airbag deployment. The nurse assesses the client for which manifestations of blunt trauma to the eye? (Select all that apply.) Diplopia Subconjunctival hemorrhage Photophobia Purulent drainage Ecchymosis around the eye
Diplopia, Subconjunctival hemorrhage, Ecchymosis around the eye. Clients who sustain blunt trauma to the eye may have a hemorrhage in the subconjunctival space. Ecchymosis around the eye, or a black eye, can lead the nurse to suspect blunt trauma. Diplopia can occur with an orbital blowout fracture. Photophobia does not occur with blunt trauma to the eye, and purulent drainage from eye does not result from a blunt trauma injury.
Which cranial nerves assist with both sensory and motor functioning in a client?
Facial, Trigeminal. The facial nerve (cranial nerve VII) assists with sensory perceptions such as pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two-thirds of the tongue. Motor functions of this nerve include movements of muscles of the face and scalp. The trigeminal nerve (cranial nerve V) assists with sensory perception from the skin of the face and scalp and mucous membranes of the mouth and nose. The motor functions of this nerve include mastication (chewing). The optic nerve (cranial nerve II) assists with sensory functions of the eye. The trochlear (cranial nerve IV) assists with the motor functions such as eye movements via superior oblique muscles. The accessory nerve (cranial nerve XI) assists with the motor functions of skeletal muscles of the pharynx and larynx and sternocleidomastoid and trapezius muscles.
A 78-year-old female client presents for an annual exam. The client admits to smoking a ½ a pack of cigarettes per day for the last 50 years. The nurse would expect that the client would also complain of a deficit in what type of sensory stimuli? Tactile Gustatory Visual Auditory
Gustatory. The two most common sensory deficits associated with tobacco use are the sense of taste (gustatory) and the sense of smell (olfactory).Visual, auditory, and tactile senses are not affected.
Depth of Burns (degrees)
Helps to determine the extent of the injury. 1st- Superficial (sunburn): dry, pink/red, blanches, heals in 3-6 days, painful. 2nd- Superficial partial thickness: Moist, pink/red, blanches, blisters, heals in 7-14 days, very painful. 2nd- Deep partial thickness: pale or variable, wet or waxy-dry, decreased blanching, heals in 2-4 weeks, less painful. 3rd- Full Thickness (3rd and 4th degree): destruction of epidermis, dermis, and some or all of subcutaneous tissue, waxy or charred, painless, does not heal, requires skin grafting. High risk for contracture due to scarring. A 4th degree burn needs specialized care (grafts will not work).
A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings?
Hypokalemia. These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose.
A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned the shower on full force. What term best describes this experience?
Illusion. An illusion is a misperception of an actual stimulus. A delusion is a fixed false belief that is unrelated to an external stimulus. Dissociation is a disturbance in the integrative functions of the client. A hallucination is a false perception with no actual external stimulus.
The family of a client with glaucoma asks how the condition develops. What information should the nurse include when responding to the family? Vitreous that leaks under the retina Loss of lens clarity associated with aging Increased intraocular pressure Inflammation caused by bacterial or viral exposure
Increased intraocular pressure. Glaucoma is characterized by increased intraocular pressure caused by increased production of vitreous humor or decreased outflow leading to damage of the optic nerve and optic disc. Cataracts occur when transparency of the crystalline lens is lost, causing opacity and cloudy vision. Retinal detachment is the separation of the sensory retinal layers with vitreous leaks under the retina; this is a condition caused by insult or injury to the eye. Conjunctivitis is inflammation of the conjunctive due to bacterial or viral exposure.
When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. What does appropriate nursing care for a client with an absent corneal reflex include?
Instilling artificial tears frequently. Instilling artificial tears frequently lubricates the eye and prevents drying of the cornea. Irrigating the eye is inappropriate; eye irrigations are used to flush foreign matter from the eye. Checking the corneal reflex every hour can lead to corneal abrasion. Taping the eyelid open can cause corneal ulceration or injury.
A nurse is explaining the myringotomy procedure to an infant's parents. What should the nurse explain about the incision?
It provides immediate relief of pressure in the middle ear. The incision for drainage produces relief of pressure and results in immediate relief of pain. This incision does not leave a scar, because healing by primary intention occurs within 24 hours. A myringotomy is performed to prevent the trauma of perforation. The incision is small and heals spontaneously within 24 hours.
A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery?
Laser technique. A laser beam causes a thermal inflammatory response, which results in a chorioretinal scar that holds the retina in place. Radiation is not used, because it destroys retinal tissue. Burr holes are used in brain, not retinal, surgery. Dermabrasion is used for acne vulgaris and other disfiguring skin conditions, not retinal surgery.
What happens in burn shock?
Massive fluid shifts from intravascular to interstitial tissues due to capillary permeability. Cardiac output is markedly compromised by fluid shifts. Shifts decrease perfusion to liver, kidney, gut. Evaporative water loss increases from lack of skin and hyperventilation. Hypermetabolic state exists. Immunosupression occurs as a result of alterations in both inflammatory and immune mechanisms.
What is the rule of nines?
Method used to determine the extent of burns. Divides the body into 11 areas, each accounting for 9% of the total body area: each upper limb = 9% each lower limb = 18% anterior and posterior trunk = 18% each head and neck = 9% perineum and genitalia = 1%
A client with diabetes mellitus complains of difficulty seeing. What would the nurse suspect as the causative factor?
Neovascularization of the retina. With diabetes mellitus, proliferation of fragile vessels and progressive thickening of the capillary basement membranes lead to decreased retinal perfusion and to hemorrhages in the eye. Hemorrhages in the eyes precipitate retinal detachment, resulting in blindness. There is an increase in serum glucose in clients with diabetes mellitus; thickening of the capillary basement membranes can occur, even if the glucose level is maintained within normal limits. Ketones do not affect retinal metabolism; retinopathy is a result of vascular changes, retinal detachment, and hemorrhage within the eye.
What should the nurse monitor to evaluate the effectiveness of carbamazepine in the management of a client's trigeminal neuralgia?
Pain intensity. Carbamazepine is administered to control pain by reducing transmission of nerve impulses in clients with trigeminal neuralgia. Liver function is monitored to detect adverse reactions to carbamazepine, not to determine therapeutic effectiveness. Carbamazepine is not given to influence cardiac output. Carbamazepine is not administered to clients with trigeminal neuralgia (tic douloureux) for its anticonvulsant properties because seizures are not present with this disorder.
A nurse talks with parents of a toddler with strabismus about why this condition should be treated in early childhood. What complication should the nurse explain may occur if strabismus is not corrected?
Partial loss of sight. If the strabismus is not corrected, sight in the affected eye will be lost because of lack of use. Cataracts do not result from strabismus. Glaucoma is caused by increased intraocular pressure, not strabismus. Refractive errors are related to visual acuity rather than strabismus.
A client is scheduled for a labyrinthectomy to treat Meniere syndrome. Which expected outcome of the procedure should be included in preoperative teaching?
Permanent irreversible deafness. The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, and other structures. A labyrinthectomy is performed to alleviate the symptom of vertigo but results in deafness on the affected side, because the organ of Corti and cochlear nerve are located in the inner ear. There is no pain associated with Meniere syndrome. Meniere syndrome is not related to cerumen production. The loss of sense of smell (anosmia) is not affected by surgery to the ear.
What are the clinical manifestations of age-related macular degeneration?
Presence of blurred and darkened vision, Scotomas (blind spots in the visual field), and Metamorphopsia (the distortion of vision); Patient may not notice early changes with their vision if it is only present in one eye.
Maria Domingo is a 78-year-old Hispanic woman who was recently diagnosed with cataracts in both eyes. Her initial symptoms presented as visual changes during the past several months and were described as cloudy vision and difficulty reading even with her glasses. Mrs. Domingo dismisses these changes as part of the aging process, but comes to the clinic at the request of her daughter. During the visit, she asks you, "How did I get this condition?" Which characteristic of the disease process related to cataracts will guide your response to Mrs. Domingo?
Proteins clump and cloud the lens of the eye as the lens ages. Assessing the client is often part of the nurse's responsibility. Therefore, understanding the pathophysiology of cataracts can help you provide better care. Most cataracts are considered senile, or forming as a normal part of the aging process. As the lens ages, fibers and proteins change and degenerate. The proteins clump and cloud the lens. This process usually begins at the periphery of the lens and spreads to involve the central portion. As the cataract continues todevelop, the entire lens may become opaque. The lens may also discolor overtime, which affects the ability to discriminate color. The other answers do not address the client's question.
Jules is a 14-year-old boy who has been diagnosed with red-green color blindness. The clinic nurse is doing some teaching regarding the color blindness. The nurse starts out by educating Jules that people who can see all colors have all of the pigments present in the cones in the retina, and people who have inherited color blindness are missing pigments within the cones of the retina. The nurse is knowledgeable about the four aspects necessary for the sensory process. Which step in the process is not functioning in the diagnosis of color blindness? Stimulus Perception Receptor Impulse conduction
Receptor. The four aspects that are required in the sensory process are stimulus, receptor, impulse conduction, and perception.With color blindness, the step that is affected is the receptor aspect. There is a lack of or dysfunctional call to convert the stimulus to a nerve impulse.The impulse, conduction, and perception aspects are unaffected.
The nurse is identifying interventions appropriate for a client with glaucoma. Which intervention should the nurse include in this client's plan of care? (Select all that apply.) Explaining the need to reduce sodium in the diet Reviewing the disease process Orienting to the environment Assisting with self-care activities Emphasizing the need for medication compliance
Reviewing the disease process, Orienting to the environment, Assisting with self-care activities, Emphasizing the need for medication compliance. Interventions that may be appropriate for inclusion in the plan of care for the client with glaucoma include orienting to the environment, assisting with self-care activities, reviewing the diseaseprocess, and emphasizing the need for medication compliance. Sodium restriction is not a part of glaucoma treatment.
The nurse is performing a physical assessment on a client reporting visual changes. Which diagnostic exam will best aid in the diagnosis of cataracts? Convergence Snellen chart Accommodation Cardinal fields of vision
Snellen chart. Utilizing a visual acuity test, such as the Snellen chart, is the simplest way to diagnose cataracts. Cardinal fields of vision will test extraocular eye movement and does not aid in the diagnosis of cataracts. Convergence indicates a neuromuscular disorder or improper eye alignment. Accommodation tests are used for neurological problems.
A client with a cervical injury reports a severe headache and nasal congestion. What should the nurse assess for?
Suprapubic distention. Suprapubic distention is a symptom of autonomic dysreflexia [1] [2], which commonly is precipitated by a distended bladder. Increased spinal reflexes and adventitious breath sounds are not associated with the symptoms of autonomic dysreflexia. The blood pressure increases suddenly with autonomic dysreflexia.
The nurse is instructing a client newly diagnosed with glaucoma on self-administration of eye medication. The nurse teaches the client to apply pressure over the lacrimal sac after administering which medication? Topical beta-adrenergic blocking agents Carbonic anhydrase inhibitors Prostaglandin analogs Adrenergic agonists
Topical beta-adrenergic blocking agents. The client needs to apply pressure over the lacrimal sac after administrating topical beta-adrenergic blocking agents. This is important to prevent systemic absorption of the medication. The client does not need to apply pressure after administrating adrenergic agonists, carbonic anhydrase inhibitors, or prostaglandin analogs.
A nurse is planning to use an otoscope to examine the auditory canal of a 4-year-old child. In what direction should the nurse pull the pinna?
Up and back. The external auditory canal curves downward and forward in a child older than 3 years and is approximately 1 inch long; for the tympanic membrane to be viewed adequately in a child of this age, the pinna must be pulled up and back. The pinna of a child younger than 3 years should be pulled down and back for an otoscopic examination. Pulling the pinna up and forward will impede visualization of the tympanic membrane. Pulling the pinna down and forward will also impede visualization of the tympanic membrane; it is the opposite of what should be done in a child older than 3 years.
What are the clinical manifestations of hyperglycemia?
Weakness, dry skin, flushing, polyuria, and thirst.