A nurse is collecting data from a client related to changes in vision. Which of the following statements indicates that the client might be developing a cataract?

"I can't see anything from the sides of my eyes."

"My vision is almost gone from the center part of my eye."

"My contact lenses just don't fit like they used to."

"l keep seeing flashes of lights moving around in my eye."

Answer and Explanation

The Correct Answer is B

A. "I can't see anything from the sides of my eyes." This statement suggests a visual field deficit, which may be indicative of conditions affecting peripheral vision, such as glaucoma, retinal detachment, or optic nerve disorders. It is not a typical symptom of cataracts.

B. "My vision is almost gone from the center part of my eye." This statement indicates a central visual impairment, which is a common symptom of cataracts. Cataracts cause clouding of the lens, leading to blurred or dimmed vision, especially in the center of the visual field. This symptom often progresses gradually over time.

C. "My contact lenses just don't fit like they used to." This statement suggests discomfort or fit issues with contact lenses and is not specifically indicative of cataracts. It may be related to changes in the shape or health of the cornea, conjunctiva, or tear film.

D. "I keep seeing flashes of lights moving around in my eye." Flashes of light in the visual field are not typical symptoms of cataracts. They may indicate other ocular conditions such as vitreous detachment, migraines with aura, or retinal disorders.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Administer pain medication as needed. Rationale: Pain management is essential for clients with traumatic brain injury (TBI) to ensure their comfort and to prevent agitation or increased intracranial pressure (ICP) due to pain. Administering pain medication as needed helps alleviate discomfort and promotes rest, which supports the client's recovery.

B. Maintain ventriculostomy at the correct position. Rationale: Ventriculostomy, also known as an external ventricular drain (EVD), is a critical component of managing intracranial pressure (ICP) in clients with traumatic brain injury. Maintaining the ventriculostomy at the correct position ensures accurate monitoring and drainage of cerebrospinal fluid (CSF), which helps control ICP levels and prevents complications such as cerebral edema.

C. Maintain the neck in the midline position. Rationale: Keeping the neck in a midline position is essential for clients with traumatic brain injury to prevent further injury to the cervical spine. Proper alignment of the neck helps maintain spinal stability and reduces the risk of exacerbating any existing spinal cord injury, which may coexist with the traumatic brain injury.

D. Elevate the head of the bed to 30 degrees. Rationale: Elevating the head of the bed to 30 degrees is recommended for clients with traumatic brain injury to promote cerebral venous drainage and reduce intracranial pressure (ICP). This position helps optimize cerebral perfusion and minimizes the risk of cerebral edema, which can occur with increased ICP.

E. Maintain enteral feedings. Rationale: Nutritional support is crucial for clients with traumatic brain injury to support healing and recovery. Enteral feedings, such as tube feedings, may be necessary if the client is unable to consume adequate nutrition orally due to impaired swallowing or altered consciousness. Providing enteral feedings ensures the client receives essential nutrients to support tissue repair and prevent malnutrition-related complications during the recovery process.

A. The aortic and mitral valves are the most commonly replaced valves. B. Mitral valve insufficiency occurs during the diastolic phase of the cardiac cycle. C. Inadequate closure of the tricuspid valve causes overload in the left ventricle. D. Aortic stenosis increases right ventricular systolic pressure and decreases afterload.

Correct Answer is A

Explanation

A. The aortic and mitral valves are the most commonly replaced valves: This statement is accurate. The aortic and mitral valves are indeed the most commonly replaced valves in cardiac valve replacement surgeries. Aortic valve replacement is commonly performed for conditions such as aortic stenosis or regurgitation, while mitral valve replacement is often indicated for mitral regurgitation or stenosis.

B. Mitral valve insufficiency occurs during the diastolic phase of the cardiac cycle: This statement is incorrect. Mitral valve insufficiency, also known as mitral regurgitation, occurs during the systolic phase of the cardiac cycle. It involves the backflow of blood from the left ventricle into the left atrium during ventricular systole, leading to volume overload of the left atrium and potentially causing symptoms such as dyspnea and fatigue.

C. Inadequate closure of the tricuspid valve causes overload in the left ventricle: This statement is incorrect. Inadequate closure of the tricuspid valve leads to regurgitation of blood from the right ventricle back into the right atrium during ventricular systole. This condition, known as tricuspid regurgitation, causes volume overload in the right atrium and ventricle, rather than overload in the left ventricle.

D. Aortic stenosis increases right ventricular systolic pressure and decreases afterload: This statement is partially correct. Aortic stenosis indeed increases left ventricular systolic pressure and decreases afterload, not right ventricular pressure. The increased afterload on the left ventricle can lead to left ventricular hypertrophy and eventually heart failure. However, aortic stenosis does not directly affect right ventricular systolic pressure.

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A nurse is collecting data from a client related to changes in vision. Which of the following statements indicates that the client might be developing a cataract?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is teaching several newly licensed nurses about cardiac valve replacement. Which of the following should the nurse include in the teaching?

Correct Answer is A

Explanation

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