A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?

Macular degeneration

Glaucoma

Diabetic retinopathy

Cataract

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because macular degeneration is a condition that affects the macula, which is the central part of the retina that is responsible for sharp and detailed vision. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field.

Choice B Reason: This is incorrect because glaucoma is a condition that affects the optic nerve, which is the nerve that connects the eye to the brain and carries visual signals. Glaucoma can cause increased pressure inside the eye, damage to the optic nerve, and loss of peripheral vision.

Choice C Reason: This is incorrect because diabetic retinopathy is a condition that affects the blood vessels in the retina, which is the layer of tissue at the back of the eye that converts light into nerve impulses. Diabetic retinopathy can cause bleeding, swelling, or leakage of fluid in the retina, and loss of vision in any part of the visual field.

Choice D Reason: This is incorrect because cataract is a condition that affects the lens, which is the transparent structure behind the pupil that focuses light onto the retina. Cataract can cause clouding or opacity of the lens, and reduced vision in all parts of the visual field.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.

Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.

Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.

Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.

A. The client needs total nursing care. B. Indicates stable neurologic status C. The client has a decline in level of consciousness but is able to protect his airway D. The client is alert and oriented.

Correct Answer is A

Explanation

Choice A Reason: The client needs total nursing care is the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which is a tool that measures the level of consciousness based on eye opening, verbal response, and motor response. A score of 6 indicates severe brain injury and coma, meaning that the client is unresponsive and dependent on others for all activities of daily living.

Choice B Reason: Indicates stable neurologic status is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A stable neurologic status means that there are no changes in the level of consciousness, vital signs, or neurological signs.

Choice C Reason: The client has a decline in level of consciousness but is able to protect his airway is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A decline in level of consciousness means that the client is less alert and responsive than normal, but still able to respond to stimuli and maintain airway patency.

Choice D Reason: The client is alert and oriented is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. Alert and oriented means that the client is fully awake and aware of person, place, time, and situation.

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A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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