A middle aged adult client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
Initiate a referral for ophthalmic evaluation as soon as possible.
Advise the client to maintain normal activities, but avoid contact sports until the spots resolve.
Tell the client to apply warm, moist compresses and notify the healthcare provider (HCP) if there is no improvement.
Instruct the client to rest, and report to the emergency department (ED) if eye pain develops.
The Correct Answer is A
Rationale:
A. Initiate a referral for ophthalmic evaluation as soon as possible: Sudden onset of flashing lights and floaters may indicate retinal detachment or a retinal tear, which are ophthalmic emergencies. Prompt evaluation by an eye specialist is critical to prevent permanent vision loss.
B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve: Continuing normal activities without urgent evaluation could delay treatment for a potentially serious retinal condition, increasing the risk of vision loss.
C. Tell the client to apply warm, moist compresses and notify the healthcare provider (HCP) if there is no improvement: Warm compresses do not treat retinal tears or detachment. Waiting for symptoms to resolve can result in permanent damage.
D. Instruct the client to rest, and report to the emergency department (ED) if eye pain develops: Retinal detachment may occur without pain, so waiting for pain to develop before seeking care is unsafe and may lead to irreversible vision loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Initiate a referral for ophthalmic evaluation as soon as possible: Sudden onset of flashing lights and floaters may indicate retinal detachment or a retinal tear, which are ophthalmic emergencies. Prompt evaluation by an eye specialist is critical to prevent permanent vision loss.
B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve: Continuing normal activities without urgent evaluation could delay treatment for a potentially serious retinal condition, increasing the risk of vision loss.
C. Tell the client to apply warm, moist compresses and notify the healthcare provider (HCP) if there is no improvement: Warm compresses do not treat retinal tears or detachment. Waiting for symptoms to resolve can result in permanent damage.
D. Instruct the client to rest, and report to the emergency department (ED) if eye pain develops: Retinal detachment may occur without pain, so waiting for pain to develop before seeking care is unsafe and may lead to irreversible vision loss.
Correct Answer is C
Explanation
Rationale:
A. Measure the blood pressure: Blood pressure can provide information about perfusion and potential hypotension due to dehydration, but it is influenced by many factors and may not accurately reflect changes in fluid volume alone.
B. Take the client's temperature: Temperature assessment is important for detecting fever or infection but does not directly measure hydration status. It offers limited information regarding fluid balance.
C. Obtain the client's weight: Daily weights are the most reliable indicator of fluid status, as changes in body weight reflect fluid loss or gain. Monitoring weight trends allows for accurate assessment of dehydration or fluid replacement efficacy.
D. Count the pulse rate: Heart rate may increase with dehydration due to compensatory mechanisms, but it is nonspecific and can be influenced by medications, activity, or anxiety, making it less accurate than weight measurement for assessing hydration.
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