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 D
Explanation
Rationale:
A. Attempt to extinguish the fire before evacuating clients: The priority is client safety. Attempting to extinguish a fire should only be done if the fire is small, contained, and the area has been cleared. Evacuation takes precedence over suppression efforts.
B. Aim the spray of the fire extinguisher at the top of the fire: The correct technique is to aim at the base of the fire to effectively cut off the fuel source. Aiming at the top will not extinguish the fire and may waste the extinguisher’s contents.
C. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows can cause the fire to spread more rapidly by feeding it with oxygen. Doors should remain closed to help contain the fire and reduce the spread of smoke.
D. Have ambulatory clients walk independently to a safe location: Encouraging ambulatory clients to move independently helps prioritize assistance for those who are immobile or require more support. This approach ensures a quicker, safer evacuation process.
Correct Answer is B
Explanation
Rationale:
A. Direct questions to the interpreter: Communication should be directed to the client, not the interpreter. Speaking directly to the client fosters rapport and respects their autonomy, while the interpreter facilitates understanding.
B. Ask the client for regular feedback: Checking in frequently with the client ensures they understand the information being conveyed. This helps clarify misunderstandings and confirms effective communication through the interpreter.
C. Incorporate acronyms into client teaching: Using acronyms can confuse clients, especially those with limited English proficiency or unfamiliarity with medical terminology. Clear, simple language without jargon is preferred.
D. Ask the client's family member to interpret: Family members may lack medical terminology knowledge, may filter information, or breach confidentiality. Professional interpreters provide more accurate and unbiased communication.
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