A client has informed the Home Health Nurse that they recently noticed distortions when looking at the Amsler grid kept on their refrigerator.
What is the appropriate action for the nurse to take?

Choice A rationale

Venous thromboembolism (VTE) is a serious complication that can occur in comatose patients. Immobility is a major risk factor for VTE, and comatose patients are often immobile. Therefore, nurses should be vigilant for signs of VTE, such as swelling, pain, or redness in the extremities.
Choice B rationale
Hemorrhage is not typically a direct complication of coma. However, the underlying cause of the coma, such as a traumatic brain injury, could potentially lead to hemorrhage.
Choice C rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can occur in comatose patients due to prolonged immobility. Regular movement and physiotherapy can help prevent this complication.
Choice D rationale
Pressure ulcers, also known as bedsores, are a common complication in comatose patients. They occur when there is prolonged pressure on the skin, usually over bony areas. Regular turning and good skin care can help prevent pressure ulcers.
Choice E rationale
Pneumonia is a common complication in comatose patients, often resulting from aspiration (inhaling food, stomach acid, or saliva into the lungs)2. Nurses should be vigilant for signs of pneumonia, such as fever, cough, and difficulty breathing.

Choice A rationale
Donepezil hydrochloride is a medication used to treat dementia related to Alzheimer’s disease. It works by improving mental function, such as memory and the ability to think and reason.
However, it is important to note that donepezil does not cure Alzheimer’s disease. The condition will worsen over time, even in people who take donepezil.
Choice B rationale
Donepezil does not limit the physical effects of Alzheimer’s disease and other dementias. While it can improve cognitive function, it does not directly impact the physical symptoms associated with these conditions.
Choice C rationale
Donepezil does not remove the patient’s insight that they have Alzheimer’s disease. It is a medication that helps to improve cognitive function, but it does not alter a person’s awareness or understanding of their condition.

Choice D rationale
Donepezil does not cure Alzheimer’s disease in any patients, let alone a small minority. It is a treatment that can help manage symptoms and improve cognitive function, but it does not stop the progression of the disease.