170 Unit 3

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

• Cardiovascular disease

• Frequent urinary tract infections

• A history of migraine headaches

• Frequent upper respiratory infections

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care?

• Avoid overuse of the eyes.

• Decrease the amount of salt in the diet.

• Eye medications will need to be administered for life.

• Decrease fluid intake to control the intraocular pressure.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages of cataract formation?

• Diplopia

• Eye pain

• Floating spots

• Blurred vision

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription would the nurse anticipate?

• Allowing bathroom privileges only

• Elevating the head of the bed to 45 degrees

• Wearing dark glasses to read or watch television

• Placing an eye patch over the client's affected eye

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem?

• Total loss of vision

• Pain in the affected eye

• A yellow discoloration of the sclera

• A sense of a curtain falling across the field of vision

A client with Ménière's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo?

• Increase sodium in the diet.

• Avoid sudden head movements.

• Lie still and watch the television.

• Increase fluid intake to 3000 mL a day.

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include?

• "The hearing aid would not be worn if an ear infection is present."

• "The ear mold for the hearing aid needs to be washed with mild soap and water once a month."

• "The hearing aid needs to be removed from the ear at the end of the day and then turned off after removal."

• "The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."

The nurse is evaluating the use of a cane for a client who sustained a stroke who has residual left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performs which action?

• Holds the cane on the right side

• Moves the cane when the right leg is moved

• Leans on the cane when the right leg swings through

• Keeps the cane 6 inches (15 cm) out to the side of the right foot

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

• "I can sit down to put on my pants and shoes."

• "My family removed all loose rugs from my bedroom."

• "I try to exercise every day and rest when I'm tired."

• "I don't need to use my walker to get to the bathroom."

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke?

• "Have you had any headaches in the past few days?"

• "Have you recently been having difficulty with seeing at nighttime?"

• "Have you had any sudden episodes of passing out in the past few days?"

• "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"