A nurse is admitting a client who has suspected retinal detachment.

Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)

"Have you had any trauma to the eye?"

"Do you regularly lift heavy objects?"

"How much sodium is in your diet?"

"Do you wear sunglasses when in direct sunlight?"

"Do you take steroids?"

Answer and Explanation

Correct Answer : A,D,E

A. "Have you had any trauma to the eye?": Trauma to the eye can be a significant risk factor for retinal detachment. Inquiring about any history of eye trauma is essential to understand potential causes or contributing factors.

D. "Do you wear sunglasses when in direct sunlight?": Prolonged exposure to sunlight without eye protection can increase the risk of retinal detachment. Wearing sunglasses with UV protection can help prevent eye damage, including retinal detachment.

E. "Do you take steroids?": Steroid use, especially long-term or systemic steroids, can increase the risk of developing retinal detachment. Steroids may lead to changes in the structure and integrity of ocular tissues, predisposing individuals to retinal detachment.

Options B and C are not directly related to the risk factors for retinal detachment:

B. "Do you regularly lift heavy objects?" - Regularly lifting heavy objects can increase pressure in the eyes, which can contribute to retinal detachment.:

C. "How much sodium is in your diet?": Sodium intake is not directly linked to the risk of retinal detachment. While diet and nutrition play a role in overall eye health, sodium consumption is not a specific risk factor for retinal detachment.

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Correct Answer is B

Explanation

A. "I can't eat as much as I used to": While changes in eating habits may be related to various factors, such as appetite changes or difficulty chewing/swallowing, this statement does not specifically indicate how hearing loss affects the client's ability to perform ADLs.

B. "I get dizzy when I nod my head": This statement suggests that the client is experiencing dizziness, which could be related to hearing loss affecting their sense of balance. Dizziness can significantly impact the client's ability to perform activities of daily living (ADLs) safely, such as walking, cooking, or bathing, as it increases the risk of falls and injury.

C. "I wash my hair every other day": This statement describes a personal hygiene habit and does not directly indicate how hearing loss affects the client's ability to perform ADLs.

D. "I walk my dog at least twice a day": This statement describes an activity the client engages in and does not directly indicate how hearing loss affects the client's ability to perform ADLs. Walking a dog does not necessarily require hearing ability, as it primarily involves physical movement and visual observation.

A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta. B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery. C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter. D. Abdominal aortic aneurysms might rupture if blood pressure is too low.

Correct Answer is C

Explanation

A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta: This statement is incorrect. Abdominal aortic aneurysms (AAAs) are most commonly found infrarenally, below the level of the renal arteries, rather than in the suprarenal region.

B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery: This statement is incorrect. An abdominal aortic aneurysm typically occurs due to weakening of the arterial wall, rather than thickening. The weakened wall allows the arterial wall to bulge or balloon out, forming an aneurysm.

C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter: This statement is correct. An abdominal aortic aneurysm is defined as a localized dilation of the abdominal aorta that exceeds 50% of the normal vessel diameter, typically greater than 30 mm in diameter. This dilation occurs due to weakening of the arterial wall, which can result from various factors such as atherosclerosis, hypertension, and genetic predisposition.

D. Abdominal aortic aneurysms might rupture if blood pressure is too low: This statement is incorrect. Abdominal aortic aneurysms are more likely to rupture when blood pressure is too high, rather than too low. Hypertension increases the pressure within the weakened arterial wall, potentially leading to rupture. Therefore, controlling blood pressure is crucial in managing abdominal aortic aneurysms to reduce the risk of rupture.

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A nurse is admitting a client who has suspected retinal detachment. Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports hearing loss. Which of the following statements indicates that the hearing loss is affecting the client's ability to perform activities of daily living (ADLs)?

Correct Answer is B

Explanation

A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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A nurse is admitting a client who has suspected retinal detachment.

Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)