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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Isolated: This term refers to something that is separate or distinct. Confusion and agitation in a client are not typically isolated but can be part of a broader clinical picture.
B. Permanent: These manifestations are not typically permanent and can often be reversed with appropriate interventions.
C. Reversible: Confusion and agitation in a client are often reversible and can be due to various factors such as medications, infections, metabolic disturbances, or other medical conditions. Identifying and addressing the underlying cause can often restore the client to their baseline mental status.
D. Unique: While every individual's presentation may have unique aspects, confusion and agitation are not considered unique manifestations in the context of acute changes in mental status. They are common symptoms that can occur due to a variety of reasons and are not exclusive to any particular condition.
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