A nurse is admitting a client who has suspected retinal detachment.
Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)
"Have you had any trauma to the eye?"
"Do you regularly lift heavy objects?"
"How much sodium is in your diet?"
"Do you wear sunglasses when in direct sunlight?"
"Do you take steroids?"
Correct Answer : A,D,E
A. "Have you had any trauma to the eye?": Trauma to the eye can be a significant risk factor for retinal detachment. Inquiring about any history of eye trauma is essential to understand potential causes or contributing factors.
D. "Do you wear sunglasses when in direct sunlight?": Prolonged exposure to sunlight without eye protection can increase the risk of retinal detachment. Wearing sunglasses with UV protection can help prevent eye damage, including retinal detachment.
E. "Do you take steroids?": Steroid use, especially long-term or systemic steroids, can increase the risk of developing retinal detachment. Steroids may lead to changes in the structure and integrity of ocular tissues, predisposing individuals to retinal detachment.
Options B and C are not directly related to the risk factors for retinal detachment:
B. "Do you regularly lift heavy objects?" - Regularly lifting heavy objects can increase pressure in the eyes, which can contribute to retinal detachment.:
C. "How much sodium is in your diet?": Sodium intake is not directly linked to the risk of retinal detachment. While diet and nutrition play a role in overall eye health, sodium consumption is not a specific risk factor for retinal detachment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Provide opportunities for education and continually evaluate the client's preferences and goals for care:
This is the most effective intervention. Providing education and involving the client (to the extent possible) in decision-making helps reduce anxiety and build trust. Even though individuals with Alzheimer's disease may have limited memory and cognitive abilities, ongoing communication about the transition and individualized care plans can help ease the process. Additionally, continuously evaluating the client's preferences and goals ensures that the care plan remains person-centered and aligns with their needs, helping to minimize relocation stress.
Correct Answer is B
Explanation
A. Dopamine: Dopamine is a catecholamine often used to increase blood pressure and cardiac output in hypotensive states. It does not directly reduce intracranial pressure (ICP).
B. Mannitol: Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with conditions such as subarachnoid hemorrhage, traumatic brain injury, or cerebral edema. It works by drawing fluid from brain tissue into the bloodstream, thereby reducing cerebral edema and ICP.
C. Nicardipine: Nicardipine is a calcium channel blocker used primarily to lower blood pressure in hypertensive emergencies. While it can indirectly impact intracranial pressure by reducing cerebral perfusion pressure, its primary mechanism of action is not targeted at reducing ICP.
D. Phenytoin: Phenytoin is an antiepileptic medication used to prevent and control seizures. While it may be indicated in clients who have experienced a subarachnoid hemorrhage to prevent seizures, it does not directly reduce intracranial pressure.
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