A nurse is caring for a patient who has a cloudy, opaque area over the lens of one eye. Which of the following visual impairments should the nurse identify this as a symptom of?

Choice A rationale

The presence of a grab bar in the bathroom is actually a safety measure that can help prevent falls. It provides support for the patient when they are getting up or moving around, reducing the risk of a fall.

Choice B rationale

An electrical cord lying across a walkway is a tripping hazard and would increase the patient’s risk of falling. It is important to keep walkways clear of clutter and potential obstacles to prevent falls.

Choice C rationale

Macular degeneration can affect the patient’s vision, making it difficult for them to see obstacles or changes in the walking surface. This can increase their risk of falling.

Choice D rationale

Throw rugs in the kitchen can easily slip or bunch up, creating a tripping hazard. They should be secured with non-slip backing or removed to reduce the risk of falls.

Choice E rationale

While a cane can provide support and improve balance, it also indicates that the patient has mobility issues, which increases their risk of falling. It is important that the patient uses the cane correctly and that it is the right height for them.

Choice A rationale: The stoma has a bluish discoloration and is bleeding extensively. This is a significant finding that requires immediate intervention. A bluish or dusky color indicates poor blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Extensive bleeding is also a concerning symptom that could indicate damage to the stoma or surrounding tissue. It’s important for the nurse to assess the stoma and notify the healthcare provider immediately to prevent further complications.

Choice B rationale: The skin surrounding the stoma has large open sores with oozing. This is another critical finding that needs immediate attention. Open sores and oozing can indicate a severe skin breakdown or infection, which can lead to further complications if not treated promptly. The nurse should clean the area, apply appropriate dressings, and consult with the wound care team or healthcare provider for further management.

Choice C rationale: The client is exhibiting a temperature of 37.8°C (100.0°F). While this temperature is not extremely high, it is slightly elevated and could be an early sign of infection, especially when considered in the context of the other symptoms the client is experiencing. The nurse should continue to monitor the client’s temperature and other vital signs, and report any significant changes to the healthcare provider.

Choice E rationale: The client reports increased nausea and vomiting. These symptoms can lead to dehydration and electrolyte imbalances, which can further complicate the client’s condition. The nurse should assess the client’s hydration status, provide interventions to manage nausea and vomiting, and monitor the client’s electrolyte levels.

Choice G rationale: The client refuses to participate in stoma care education. While this may not seem like an immediate medical concern, it is a significant issue that requires intervention. The client’s refusal to learn about stoma care can hinder their recovery and long-term management of the ileostomy. The nurse should explore the reasons behind the client’s refusal, provide emotional support, and use different strategies to encourage the client’s participation in stoma care education.