Exhibits

The nurse performs an initial focused assessment of the client. Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of a disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

Choice A reason: Comparing the capillary refill in the hands is a useful assessment for evaluating peripheral circulation, but it is not specific to diagnosing carpal tunnel syndrome. Carpal tunnel syndrome involves compression of the median nerve, and capillary refill does not provide information about nerve compression.

Choice B reason: Determining the client's sleeping position may provide insight into factors that exacerbate symptoms, but it does not directly assess for carpal tunnel syndrome. While certain positions might worsen the condition, this information alone is not diagnostic.

Choice C reason: Applying firm pressure over the ulnar artery is not relevant to assessing carpal tunnel syndrome. The ulnar artery supplies blood to the hand, but carpal tunnel syndrome involves the median nerve, not the ulnar artery.

Choice D reason: Tapping the client's wrists to locate the pain, known as Tinel's sign, is a specific test for carpal tunnel syndrome. Tinel's sign is positive when tapping over the median nerve at the wrist elicits tingling or pain in the fingers, indicating nerve compression.

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.