A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?
Nystagmus
Astigmatism
Loss of central vision
Client reports sharp pain
The Correct Answer is C
Rationale:
A. Nystagmus: Nystagmus is characterized by involuntary eye movements and is typically associated with vestibular disorders, multiple sclerosis, or congenital conditions. It is not a symptom of macular degeneration, which primarily affects the retina.
B. Astigmatism: Astigmatism is a refractive error due to an irregularly shaped cornea or lens. It is unrelated to macular degeneration, which involves degeneration of the macula—the part of the retina responsible for sharp central vision.
C. Loss of central vision: Macular degeneration leads to progressive deterioration of the macula, resulting in blurred or complete loss of central vision while peripheral vision remains intact. This is a hallmark symptom and significantly affects activities like reading and recognizing faces.
D. Client reports sharp pain: Macular degeneration does not typically cause pain. It is a painless condition, and the presence of sharp eye pain may suggest another acute ocular issue such as glaucoma or injury, not related to macular changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A middle adult man: Although some adults up to age 45 can receive the HPV vaccine based on shared decision-making, routine vaccination is not typically initiated in middle adulthood. The vaccine is most effective when given prior to exposure to HPV, ideally during adolescence.
B. A teenage boy: The HPV vaccine is routinely recommended for all adolescents, including boys, starting at ages 11 to 12, with catch-up vaccination through age 26 if not previously vaccinated. It helps prevent various HPV-related cancers and is most effective when administered before sexual activity begins.
C. An older adult woman: HPV vaccination is not routinely recommended for individuals older than 26. While it may be considered up to age 45 in certain situations, it is less beneficial after potential HPV exposure, and routine administration in this age group is not advised.
D. A preschool-age girl: The HPV vaccine is not recommended for children under 9 years old. Initiating the vaccine too early is not effective or necessary, as the immune system response and timing related to potential HPV exposure are best addressed in early adolescence.
Correct Answer is C
Explanation
Rationale:
A. Respiratory acidosis: Chronic diarrhea typically causes metabolic acidosis due to loss of bicarbonate in the stool, not respiratory acidosis. Respiratory acidosis results from hypoventilation and CO₂ retention, unrelated to diarrhea.
B. Hypertension: Chronic diarrhea often leads to fluid and electrolyte imbalances causing hypotension or low blood pressure due to dehydration, rather than hypertension.
C. Hypokalemia: Diarrhea causes significant potassium loss through the gastrointestinal tract, leading to hypokalemia. Low potassium levels can result in muscle weakness, cramps, and cardiac arrhythmias.
D. Hypermagnesemia: Magnesium is usually lost during diarrhea, which more commonly leads to hypomagnesemia rather than elevated magnesium levels. Hypermagnesemia is rare unless there is excessive intake or renal failure.
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