During a routine eye examination, an older client reports decreased peripheral vision and is found to have elevated intraocular pressures. Ophthalmic drops are prescribed for primary open-angle glaucoma (POAG). Which intervention(s) should the nurse include in this client's plan of care? Select all that apply.
Review written and verbal instructions for a reduced sodium diet.
Teach strategies for aseptic administration of the eye drops.
Describe how the use of the eye drops will help improve peripheral vision.
Teach to apply pressure over the inner eye corner after eye drops.
Explain the need to continue eye drops for the rest of their life.
Correct Answer : B,D,E
Choice A reason: Reviewing written and verbal instructions for a reduced sodium diet is not directly related to the management of primary open-angle glaucoma (POAG). While a healthy diet can contribute to overall well-being, dietary sodium does not have a significant impact on intraocular pressure or glaucoma management. Therefore, this intervention does not directly address the client's primary condition of POAG.
Choice B reason: Teaching strategies for aseptic administration of the eye drops is a critical intervention for clients with POAG. Proper administration of ophthalmic drops is essential to avoid contamination and infection. Aseptic techniques include washing hands before administering the drops, avoiding touching the dropper tip to any surface (including the eye), and ensuring that the dropper cap is replaced tightly after use. These measures help maintain the sterility of the medication and prevent complications such as eye infections, which can exacerbate the client's condition.
Choice C reason: Describing how the use of the eye drops will help improve peripheral vision is not entirely accurate in the context of POAG. The primary goal of ophthalmic drops for POAG is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving the remaining vision. These drops do not typically improve peripheral vision that has already been lost. Educating the client with accurate information about the purpose and benefits of the drops helps set realistic expectations and encourages adherence to the treatment regimen.
Choice D reason: Teaching the client to apply pressure over the inner eye corner (punctal occlusion) after administering eye drops is an important intervention. Punctal occlusion helps prevent the medication from draining into the tear duct and being absorbed systemically. This technique increases the contact time of the medication with the eye, enhancing its effectiveness and reducing potential systemic side effects. Clients should be instructed to gently press the inner corner of the eye for a few minutes after instilling the drops to ensure maximum benefit.
Choice E reason: Explaining the need to continue eye drops for the rest of their life is essential for clients with POAG. Glaucoma is a chronic condition that requires lifelong management to control intraocular pressure and prevent progression of the disease. Discontinuing the medication can lead to elevated intraocular pressures and irreversible vision loss. Clients should understand the importance of adherence to their prescribed treatment regimen and the lifelong commitment to managing their condition to preserve their vision and quality of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Encouraging the client to lie down and rest after meals is not advisable for someone with gastroesophageal reflux. Lying down after eating can exacerbate symptoms by allowing stomach acid to more easily flow back into the esophagus. It's recommended that clients stay upright for at least 2-3 hours after meals.
Choice B reason: Avoiding high-fiber foods is not a standard recommendation for managing gastroesophageal reflux. In fact, a diet high in fiber can benefit overall digestive health and help prevent constipation. The key dietary advice usually involves avoiding trigger foods such as spicy, fatty, or acidic foods.
Choice C reason: Elevating the head of the bed on blocks is an effective way to manage gastroesophageal reflux, especially at night. This position helps keep stomach acid in the stomach and prevents it from flowing back into the esophagus, reducing symptoms such as heartburn.
Choice D reason: Instructing the client to use antacids only as a last resort is not necessarily accurate advice. While antacids can provide symptomatic relief, they are often used as part of a comprehensive management plan for gastroesophageal reflux. However, lifestyle modifications and dietary changes are also crucial.
Correct Answer is C
Explanation
Choice A reason: Reports of a bad taste in the mouth can be associated with various conditions, including metabolic imbalances, but it is not typically an immediate concern in the context of AKI.
Choice B reason: Low concentrated urine output (oliguria) is a common finding in AKI and indicates decreased kidney function. While it is an important assessment finding, it does not usually require immediate intervention compared to signs of severe complications.
Choice C reason: Dyspnea (difficulty breathing) and sinus tachycardia (rapid heart rate) can indicate fluid overload or pulmonary edema, which are serious complications of AKI. These symptoms require immediate intervention to prevent respiratory distress and potential cardiac complications.
Choice D reason: A productive cough and fever may suggest an infection, which is important to address but not necessarily an immediate life-threatening issue compared to dyspnea and tachycardia in the context of AKI.
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