A nurse is caring for a patient who has impaired speech. What actions should the nurse take?

Choice A rationale

Glaucoma is a condition that damages the eye’s optic nerve and can result in vision loss and blindness. However, it doesn’t cause a cloudy, opaque area over the lens of the eye.

Choice B rationale

Diabetic retinopathy is a diabetes complication that affects eyes. It’s caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina). But it doesn’t cause a cloudy, opaque area over the lens of the eye.

Choice C rationale

Macular degeneration is a medical condition which may result in blurred or no vision in the center of the visual field. But it doesn’t cause a cloudy, opaque area over the lens of the eye.

Choice D rationale

A cataract is a clouding of the lens in the eye that affects vision. Cataracts are very common in older people. Symptoms of cataracts include cloudy or blurry vision.

Choice A rationale

While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.

Choice B rationale

Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.

Choice C rationale

Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.

Choice D rationale

Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.