The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?
“I should avoid activities that increase eye pressure, like heavy lifting.”
“Glaucoma can lead to vision loss if not managed properly.”
“Eye drops will cure my glaucoma and restore my vision.”
“Regular eye exams are important to monitor my condition.”
The Correct Answer is C
Choice A reason: Avoiding heavy lifting is correct, as it increases intraocular pressure (IOP) in glaucoma, damaging the optic nerve. This statement shows understanding, as limiting activities that elevate IOP protects retinal ganglion cells, reducing progression risk, aligning with proper glaucoma management strategies.
Choice B reason: Glaucoma can cause vision loss if untreated, as elevated IOP damages optic nerve fibers, leading to irreversible blindness. This statement reflects accurate understanding of the disease’s progressive nature, emphasizing the need for management to preserve vision, requiring no further teaching.
Choice C reason: Eye drops (e.g., timolol) reduce IOP but do not cure glaucoma or restore vision, as optic nerve damage is irreversible. This statement indicates misunderstanding, as glaucoma is chronic, requiring lifelong management to slow progression, necessitating further teaching to correct this misconception.
Choice D reason: Regular eye exams monitor IOP and optic nerve health in glaucoma, preventing progression. This statement shows understanding, as consistent follow-up detects changes in retinal nerve fiber layer thickness, ensuring timely adjustments in therapy, aligning with effective disease management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Orientation to person and place only suggests confusion, common in right hemisphere stroke affecting non-dominant cognition. This is not immediately life-threatening. Pupillary dilation indicates increased intracranial pressure (ICP) or herniation, a critical emergency requiring urgent intervention to prevent brain stem damage or death.
Choice B reason: Unequal hand grip strengths indicate hemiparesis, typical in right hemisphere stroke affecting left-sided motor function. This is expected and not acutely life-threatening. Pupillary dilation signals rising ICP or herniation, necessitating immediate intervention to prevent catastrophic neurological decline, making it the priority finding.
Choice C reason: Left-sided facial drooping and dysphagia are common in right hemisphere stroke, reflecting contralateral cranial nerve deficits. These are serious but not immediately life-threatening. Pupillary dilation indicates potential herniation from ICP, requiring urgent intervention like mannitol to prevent brain stem compression and fatal outcomes.
Choice D reason: Ipsilateral pupillary dilation in right hemisphere stroke signals increased ICP or herniation, compressing the oculomotor nerve (CN III), impairing pupillary constriction. This life-threatening emergency indicates impending brain stem compromise, requiring immediate intervention with ICP-lowering measures or surgery to prevent irreversible damage or death.
Correct Answer is B
Explanation
Choice A reason: Administering warfarin with an INR of 4.8 is dangerous, as it exceeds the therapeutic range (2.0–3.0), indicating excessive anticoagulation. This risks bleeding, as warfarin inhibits vitamin K-dependent clotting factors. Notifying the provider ensures dose adjustment or reversal, preventing hemorrhage, making this action unsafe.
Choice B reason: An INR of 4.8 indicates over-anticoagulation in atrial fibrillation, increasing bleeding risk due to warfarin’s inhibition of clotting factors. Notifying the provider is critical for dose reduction or vitamin K administration, addressing the pathophysiological risk of hemorrhage, ensuring patient safety and preventing life-threatening complications.
Choice C reason: Encouraging green leafy vegetables, high in vitamin K, counteracts warfarin, lowering INR, but is inappropriate without provider guidance at INR 4.8, risking bleeding. Provider notification ensures controlled management, as unregulated dietary changes disrupt anticoagulation stability, making this action potentially harmful.
Choice D reason: Monitoring for bleeding is important but secondary to notifying the provider at INR 4.8, indicating critical over-anticoagulation. Immediate provider intervention adjusts warfarin or administers reversal agents, preventing hemorrhage. Monitoring delays urgent action needed to correct the clotting factor imbalance, making it less immediate.
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