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. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.
B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.
C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.
D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.
Correct Answer is ["A","B","C","E"]
Explanation
Rationale:
• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.
• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.
• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.
• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.
• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.
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