A nurse is teaching a client who has macular degeneration about how to use an Amsler grid. Which of the following statements should the nurse include in the teaching?
"Note if you see any flashing bright lights on the grid."
"Check to see if the lines on the grid are blurry or distorted."
"Monitor for the lines on the grid to change in color or brightness."
"Watch for floating dark spots on the grid."
The Correct Answer is B
A. "Note if you see any flashing bright lights on the grid." Flashing lights are not typically associated with macular degeneration. This symptom is more commonly associated with conditions like retinal detachment or migraine headaches.
B. "Check to see if the lines on the grid are blurry or distorted." This statement is correct. The Amsler grid is used to detect changes in central vision, which are common in macular degeneration. Patients with macular degeneration may perceive wavy or distorted lines instead of straight lines when looking at the grid, indicating central vision loss.
C. "Monitor for the lines on the grid to change in color or brightness." Changes in color or brightness of the lines on the grid are not typical features of macular degeneration. This statement does not accurately reflect the purpose of using an Amsler grid for macular degeneration.
D. "Watch for floating dark spots on the grid." Floating dark spots (floaters) are not typically associated with macular degeneration. Floaters are more commonly associated with conditions like posterior vitreous detachment or retinal detachment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Ensuring that the client and their family are kept informed about the client's care
Rationale:
A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.
B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.
C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.
D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.
Correct Answer is A
Explanation
A. "I need to walk slowly as I lose my balance often": This statement indicates a potential safety concern related to balance issues while walking. Loss of balance can increase the risk of falls, especially in individuals with peripheral artery disease (PAD) who may already have compromised circulation and reduced sensation in their legs. The nurse should report this statement to the provider for further evaluation and intervention to prevent falls and promote safety.
B. "I don't go out much because of the pain in my legs" : While this statement suggests that the client experiences pain in their legs, it does not directly indicate a safety concern that requires immediate reporting to the provider. Pain management strategies may be discussed with the provider to address this issue.
C. "It makes me sad that I can't keep up with my grandchildren" : While this statement reflects emotional distress related to the client's inability to participate fully in activities with their grandchildren, it does not indicate a specific safety concern that requires reporting to the provider. However, addressing the client's emotional well-being is important for overall holistic care.
D. "I have a small-healed area on my spine that is painful" : This statement describes a painful area on the client's spine but does not directly relate to potential safety concerns associated with PAD. The nurse may further assess this issue and include it in the client's overall assessment, but it does not require immediate reporting to the provider for safety concerns related to PAD.
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