A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.
When the client exhales, the nurse hears continuous high-pitched whistling sound.
The nurse should document this as?

Choice A rationale

Without treatment, glaucoma can lead to blindness due to the progressive damage it causes to the optic nerve. Elevated intraocular pressure damages the optic nerve fibers, leading to peripheral vision loss and eventually total blindness if untreated.

Choice B rationale

Double vision is not a common symptom of glaucoma. Instead, glaucoma typically presents with symptoms like gradual peripheral vision loss, eye pain, and halos around lights.

Choice C rationale

Glaucoma is primarily caused by increased intraocular pressure, either due to overproduction of aqueous humor or improper drainage, not inadequate fluid production.

Choice D rationale

Use of eye drops helps to control intraocular pressure but does not improve vision; it helps to prevent further damage to the optic nerve.

Choice A rationale

The optic nerve (CN II) is responsible for vision, transmitting visual information from the retina to the brain. Dysfunction of the optic nerve would result in visual disturbances, such as loss of vision or changes in visual acuity, rather than difficulty with tongue movement. This nerve does not control motor functions of the tongue.

Choice B rationale

The abducens nerve (CN VI) controls the lateral rectus muscle of the eye, which is responsible for moving the eye outward, away from the nose. Dysfunction of the abducens nerve would result in issues with eye movement, such as double vision or inability to move the eye laterally, not tongue movement. It does not play a role in tongue motor control.

Choice C rationale

The hypoglossal nerve (CN XII) controls the muscles of the tongue, enabling movements necessary for speech, swallowing, and mastication. Dysfunction of this nerve would result in difficulty protruding the tongue and reduced strength during resistance testing. Symptoms can include atrophy of the tongue muscles, fasciculations, and deviation of the tongue to one side when extended.

Choice D rationale

The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance, transmitting sound and equilibrium information from the inner ear to the brain. Dysfunction of the vestibulocochlear nerve would lead to symptoms such as hearing loss, tinnitus, or balance disorders like vertigo. It does not affect the motor control of the tongue.