Exhibits

The nurse discusses the keep to balance energy intake and output to maintain weight

Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

Rationale

A. Acute pain following laser trabeculoplasty could indicate increased intraocular pressure, inflammation, or other complications. Reporting the pain to the surgeon allows for prompt evaluation and intervention, which may include further assessment of intraocular pressure, examination of the surgical site, and consideration of additional treatment modalities such as pain management or anti- inflammatory medications.

B. Postoperative antibiotics are typically prescribed to prevent infection after surgery. However, acute pain alone may not indicate an infection, and starting antibiotics without assessing the cause of pain could delay appropriate management. Antibiotics are not indicated as the first-line response to acute pain in this context.

C. Eye shields are commonly used after eye surgery to protect the eye from light and potential trauma. While important for protecting the eye, applying eye shields addresses a different aspect of postoperative care (protecting the eye from external factors), rather than addressing the acute pain reported by the client.

D. Nausea and vomiting can sometimes occur postoperatively due to anesthesia or medications. However, administering an antiemetic is not the appropriate action in response to acute eye pain following laser trabeculoplasty. It does not address the underlying cause of the pain and is not part of the standard immediate management for this situation.

Rationale

A. This action helps maintain adequate cerebral perfusion pressure and venous drainage, which is important in suspected stroke cases. It supports optimal cerebral blood flow and reduces the risk of increased intracranial pressure. However, it's not the immediate intervention required for this client. The primary focus initially is on diagnostic evaluation and stabilization.

B. Elevating the joints on the affected side can help reduce dependent edema and promote circulation. This intervention is part of ongoing nursing care to prevent complications like deep vein thrombosis (DVT) in stroke patients who may have reduced mobility. While important, it is not the immediate priority in the acute phase of management.

C. Gathering a focused history is crucial to understanding potential causes or exacerbating factors contributing to the client's symptoms While important, it is not the immediate priority in the acute phase of management.

D. Intermittent pneumatic compression devices (IPC) are used to prevent deep vein thrombosis (DVT) by enhancing venous return and preventing stasis in the lower extremities. While DVT prevention is important in stroke patients, it is not the immediate intervention required for the client's acute neurological symptoms.