A nurse is assessing a client who has vision impairment related to acute angle-closure glaucoma. Which of the following manifestations should the nurse expect?
A yellowed sclera
Brisk pupil reactivity
Client reports a curtainlike obstruction over the visual field
Client reports seeing colored halos around lights
The Correct Answer is D
A) A yellowed sclera:
A yellowed sclera is typically associated with jaundice, which is related to liver conditions, not acute angle-closure glaucoma. This symptom is not indicative of glaucoma.
B) Brisk pupil reactivity:
In acute angle-closure glaucoma, the pupil is often mid-dilated and sluggish to react to light due to increased intraocular pressure. Brisk pupil reactivity is not a characteristic finding in this condition.
C) Client reports a curtainlike obstruction over the visual field:
A curtainlike obstruction over the visual field is usually associated with retinal detachment, not acute angle-closure glaucoma. This description does not align with the symptoms of glaucoma.
D) Client reports seeing colored halos around lights:
Seeing colored halos around lights is a classic symptom of acute angle-closure glaucoma. This occurs due to the elevated intraocular pressure affecting the corneal surface and causing light diffraction. This manifestation is a key indicator of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.
B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.
C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.
D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.
Correct Answer is ["B","C","E"]
Explanation
A) Urticaria:
Urticaria, or hives, is a skin reaction characterized by itchy, raised welts. It is not typically associated with a small bowel obstruction, which primarily affects the gastrointestinal system rather than the skin.
B) Vomiting:
Vomiting is a common symptom of a complete small bowel obstruction. It occurs due to the blockage in the intestines, which prevents the passage of contents, leading to nausea and vomiting as the body tries to expel the obstruction.
C) Distended abdomen:
A distended abdomen is expected in cases of small bowel obstruction. The blockage causes a buildup of gas and fluids, leading to abdominal swelling and distention as the normal passage of intestinal contents is impeded.
D) Fluid overload:
Fluid overload is not a typical manifestation of a small bowel obstruction. Instead, dehydration and electrolyte imbalances are more likely due to vomiting and the inability to absorb fluids and nutrients properly.
E) Obstipation:
Obstipation, or severe constipation with an inability to pass stool or gas, is a key sign of a complete small bowel obstruction. The obstruction prevents the normal movement of intestinal contents, leading to a cessation of bowel movements.
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