A nurse is planning care for an older adult client.
The nurse should plan to monitor the client for which of the following?
Widened peripheral vision.
Increase in accommodation to near vision.
Eyes with large pupils.
Infections of the eye.
The Correct Answer is B
Choice A rationale:
Widened peripheral vision. This choice is not an expected change in an older adult's vision. As individuals age, peripheral vision may diminish, but it doesn't typically widen. Therefore, this choice is not appropriate.
Choice C rationale:
Eyes with large pupils. Older adults often experience changes in the size of their pupils due to the aging process. Pupils may become smaller and less responsive to light, not larger. Thus, this choice is not accurate.
Choice D rationale:
Infections of the eye. While eye infections can occur in any age group, there's no specific reason to monitor an older adult for eye infections unless there are signs or symptoms suggesting an issue. It's not a routine aspect of care for older adults. Now, let's discuss the rationale for the correct answer, choice B:
Choice B rationale:
Increase in accommodation to near vision. This is the correct answer because it is a common age-related change in vision known as presbyopia. As individuals age, their ability to accommodate or focus on near objects diminishes. This change typically begins in the early 40s and progresses over time. It's a result of the lens of the eye becoming less flexible. Older adults may need reading glasses or bifocals to improve their near vision. The nurse should plan to monitor for this change as part of routine care for an older adult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
When caring for a client at the end of life who is unresponsive, it is essential to maintain a compassionate and supportive presence. Continuing to talk to the client as if they are awake is a respectful and therapeutic approach. Even though the client may not respond verbally, they may still be able to hear and sense the presence of their loved ones and the healthcare team. This communication can provide comfort and reassurance.
Choice B rationale:
Limiting the client's visitors to one at a time is a reasonable consideration, as it can help reduce potential overwhelm and maintain a calm environment. However, this choice should be based on the client's and family's preferences. Some clients and families may prefer to have multiple visitors present for support and companionship during this difficult time.
Choice C rationale:
Avoiding touching the client is not recommended when caring for an unresponsive client at the end of life. Physical touch, when gentle and respectful, can convey comfort and support. The nurse should be sensitive to the client's preferences and the family's wishes regarding physical contact.
Choice D rationale:
Whispering when talking in the client's room is not necessary. While it's important to maintain a quiet and peaceful environment, speaking in a normal tone is appropriate. The client may still be able to hear and may find comfort in the familiar voices of their loved ones and the healthcare team. .
Correct Answer is A
Explanation
Choice A rationale:
Secondary prevention involves early detection and intervention to prevent the progression of a disease. In the case of breast cancer, a mammogram is a secondary prevention measure because it aims to detect cancer at an early stage, especially in individuals with a family history of the disease. Early detection can lead to timely treatment and improved outcomes.
Choice B rationale:
Echocardiograms are typically used to assess the function of the heart and diagnose existing heart conditions. While it is a valuable diagnostic tool, it is not an example of secondary prevention, which is focused on early detection and prevention of disease.
Choice C rationale:
Influenza vaccination is an example of primary prevention, as it aims to prevent the initial occurrence of the disease by providing immunity against the influenza virus. It is not considered a form of secondary prevention.
Choice D rationale:
Not scheduling a series of tests for an asymptomatic client does not fit the definition of secondary prevention. Secondary prevention involves screening and early detection in individuals at risk or with early signs of a disease to prevent its progression. An asymptomatic client without known risk factors may not require such testing as a preventive measure.
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