A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Choice A Reason: This is correct because incorporating foods rich in vitamin C in the diet can help prevent or delay macular degeneration. Vitamin C is an antioxidant that can protect the cells of the macula, which is the central part of the retina that is responsible for sharp and detailed vision, from oxidative stress and damage. The nurse should also advise the client to consume foods rich in other antioxidants, such as vitamin E, zinc, lutein, and zeaxanthin.

Choice B Reason: This is correct because receiving injections into the eye can help treat macular degeneration. Injections are a form of anti-vascular endothelial growth factor (anti-VEGF) therapy, which can block abnormal blood vessel growth and leakage in the macula that can cause vision loss. The nurse should explain to the client how often and how long they need to receive injections and what side effects or complications they may experience.

Choice C Reason: This is incorrect because vision will not be restored after using eye drops for macular degeneration. Eye drops are not a proven or effective treatment for macular degeneration, which is a chronic and progressive condition that causes irreversible vision loss. The nurse should reinforce education by informing the client that eye drops may only provide temporary relief of dryness or irritation, but they will not improve or restore vision.

Choice D Reason: This is correct because vision will become progressively more blurry with macular degeneration. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field. The nurse should educate the client on how to cope with vision loss and use adaptive devices, such as magnifiers, large-print books, or voice-activated technology.

Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.

Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.

Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.

Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.