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 C

Explanation

A. Third spacing: Third spacing refers to the shifting of fluid from the intravascular space into the interstitial space, leading to decreased circulating volume. While third spacing can contribute to hypovolemic shock, it is not specific to obstructive shock.

B. Cardiomyopathy: Cardiomyopathy is a condition characterized by abnormalities in the heart muscle structure and function. While cardiomyopathy can lead to heart failure, it is not directly associated with obstructive shock.

C. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing its ability to fill properly. This condition can lead to obstructive shock due to decreased cardiac output. Signs and symptoms include hypotension, muffled heart sounds, distended neck veins, and pulsus paradoxus.

D. Ruptured aneurysm: A ruptured aneurysm can lead to hypovolemic shock due to acute blood loss. While it can cause significant hemodynamic instability, it is not a characteristic diagnosis of obstructive shock.

A. Intermittent pneumatic compression pumps B. Ankle-brachial index test C. Layered wraps D. Elevation of legs E. Exercise

Correct Answer is ["A","C","D","E"]

Explanation

A. Intermittent pneumatic compression pumps: Intermittent pneumatic compression pumps can help improve circulation in the lower extremities by assisting with venous return. These devices inflate and deflate sequentially, promoting venous blood flow and reducing edema in clients with peripheral venous disease.

B. Ankle-brachial index test: The ankle-brachial index (ABI) test is a non-invasive vascular study used to assess peripheral arterial disease (PAD). It compares the blood pressure in the ankle with the blood pressure in the arm to evaluate arterial circulation.

C. Layered wraps: Layered wraps, such as compression bandages or stockings, are typically used in the management of venous insufficiency and venous ulcers. They are not as commonly utilized in peripheral venous disease, however, they may be beneficial for some clients with PVD.

D. Elevation of legs: Elevating the legs above the level of the heart can help reduce edema and improve venous return in clients with peripheral venous disease. Gravity assists in draining blood from the lower extremities back toward the heart, thereby reducing swelling and discomfort.

E. Exercise: Regular physical activity, particularly lower extremity exercises such as walking, can promote venous return and improve circulation in clients with peripheral venous disease. Exercise helps to pump blood back to the heart, reducing venous stasis and the risk of complications such as venous thrombosis.

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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 providing care for a client experiencing obstructive shock. Which of the following diagnoses should the nurse expect?

Correct Answer is C

Explanation

A nurse is planning care for a client who has peripheral venous disease. Which of the following interventions should the nurse include in the plan of care? (Select All that Apply.)

Correct Answer is ["A","C","D","E"]

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.)