A middle-aged 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

Instruct the client to rest, and report to the emergency department if eye pain develops.

Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Answer and Explanation

The Correct Answer is A

A.   The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B.   This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C.   While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D.   Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

A. "I will lift weights every other day." B. "I will be able to stand as long as my legs do not hurt." C. "I will avoid sitting and crossing my legs." D. "I will need to get someone to walk my dog."

Correct Answer is C

Explanation

A. Weight lifting can be beneficial for overall fitness, but for someone with chronic venous insufficiency, the focus should be on activities that improve venous return and avoid excessive strain on the legs. Heavy weight lifting might exacerbate symptoms or lead to further complications.
B. For individuals with chronic venous insufficiency, prolonged standing can worsen symptoms such as swelling and pain. It’s important to avoid standing for long periods and to use measures such as leg elevation and compression stockings to manage symptoms.
C. This statement reflects an understanding of good practices for managing chronic venous insufficiency. Sitting for prolonged periods and crossing the legs can impede venous return and worsen symptoms of CVI. It is advised to avoid these practices and instead frequently change positions, elevate the legs, and use compression stockings to improve circulation.
D. While getting help to walk a dog could be beneficial if the client is unable to walk or if walking exacerbates symptoms, this statement does not directly address key aspects of managing chronic venous insufficiency. Regular walking is generally recommended to enhance venous return and prevent complications, assuming it is done within the client’s tolerance and ability.

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A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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