A home health nurse is performing an eye assessment for an older adult client. Which of the following findings is the priority for the nurse to report to the provider?
Conjunctivitis
Increased sensitivity to glare
Decreased near vision
Hemianopsia
The Correct Answer is D
Hemianopsia is a visual field defect in which there is a loss of vision in one-half of the visual field. It can be caused by a number of conditions, including stroke, brain tumors, and traumatic brain injury. It is a significant finding that requires immediate reporting to the provider, as it can indicate a serious underlying condition that requires further evaluation and treatment. Hemianopsia can significantly impact a client's ability to perform activities of daily living, mobility, and safety. Conjunctivitis is inflammation of the conjunctiva, which can cause redness, itching, and discharge. While it is important
to assess and treat conjunctivitis, it is not a priority finding that requires immediate reporting to the provider. Increased sensitivity to glare is a common age-related change in vision, and while it can be bothersome, it is not typically a priority finding that requires immediate reporting to the provider. Decreased near vision is another common age-related change in vision, and while it can be an important finding to address with the client, it is not typically a priority finding that requires immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
The correct answers are A, D, and E. Primary prevention activities aim to prevent the onset of disease or injury. Teaching a class about the risks of cigarette smoking and organizing a program to promote skateboard safety are examples of primary prevention activities. Lobbying for funding for health promotion efforts is also a primary prevention activity because it aims to prevent the occurrence of illness or injury in the community. Creating a plan of care for children who have a diagnosis of diabetes mellitus and recommending a seating arrangement for a child in a body cast are examples of secondary prevention activities, which aim to detect and treat health problems early to prevent complications.
Correct Answer is C
Explanation
When caring for a client with terminal cancer who expresses a desire to discontinue enteral tube feedings, the nurse's priority is to ensure that the client's wishes are respected and appropriate steps are taken. The most suitable action is:
c) Explain the process for completing a living will.
A living will is a legal document that outlines a person's preferences regarding medical treatment in the event they are unable to communicate their wishes. In this situation, the client can express their desire to forgo enteral tube feedings through a living will, ensuring that their wishes are documented and legally recognized.
The other options may not be as appropriate:
a) Request the facility chaplain to visit the client:While spiritual and emotional support is important, the immediate concern is ensuring the client's autonomy in decision-making regarding medical interventions.
b) Ask the client to sign an informed consent form:Informed consent typically pertains to specific medical procedures, and discontinuing enteral tube feedings is more aligned with the broader context of advance care planning.
d) Complete an against medical advice form:This form is typically used when a patient refuses a recommended treatment against the medical team's advice. However, in this case, the client is expressing their own treatment preferences, and the focus should be on facilitating advance care planning and documentation.
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