A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?

"I can't seem to get reading materials far enough away to see the words."

"I'm having more difficulty telling the difference between blues and greens."

"I've noticed that there is a gray ring around the colored part of my eye."

"In the last day, I have had a severe headache and pain around my right eye."

Answer and Explanation

The Correct Answer is D

Rationale:

A. "I can't seem to get reading materials far enough away to see the words." This statement may indicate presbyopia, which is a common age-related change in vision. It does not require immediate intervention, though corrective lenses may help.

B. "I'm having more difficulty telling the difference between blues and greens." This could indicate age-related changes in color vision or cataracts, which is common but not immediately concerning. It does not represent an urgent need for intervention.

C. "I've noticed that there is a gray ring around the colored part of my eye." This could suggest a cataract, which is common in older adults. However, it is a chronic condition that progresses slowly and is not an emergency.

D. "In the last day, I have had a severe headache and pain around my right eye." This is a priority, as it could indicate acute angle-closure glaucoma, a medical emergency that requires immediate attention to prevent permanent vision loss. Symptoms include severe headache, eye pain, nausea, and blurred vision, all of which need urgent assessment and intervention.

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Correct Answer is ["A","D"]

Explanation

Rationale:

A. Strict I&O: Monitoring intake and output is essential due to decreased urination, flank pain, and impaired kidney function. The elevated BUN and creatinine levels suggest renal impairment, and strict I&O helps assess fluid balance.

B. Increase fluid intake: While hydration is important, increasing fluids should be done cautiously due to the client’s impaired kidney function. Given the elevated BUN and creatinine, the kidneys may not manage increased fluids without worsening fluid retention.

C. Encourage protein supplements: Protein supplements are not recommended in kidney dysfunction, as they can worsen renal strain. Elevated BUN and creatinine levels indicate kidney impairment, and protein intake may aggravate the condition.

D. Strain all urine: Straining all urine is necessary to capture any possible kidney stones, blood clots, or debris. The reddish-brown urine and positive blood in the urinalysis suggest hematuria, which may need further investigation.

A. Loss of peripheral vision B. Deviation of the tongue from midline C. Disequilibrium with movement D. Inability to smell

Correct Answer is C

Explanation

Rationale:

A. Loss of peripheral vision: Loss of peripheral vision is associated with dysfunction of the optic nerve (cranial nerve II), not the vestibulocochlear nerve (cranial nerve VIII).

B. Deviation of the tongue from midline: Deviation of the tongue from the midline indicates dysfunction of the hypoglossal nerve (cranial nerve XII), not the vestibulocochlear nerve.

C. Disequilibrium with movement: The vestibulocochlear nerve (cranial nerve VIII) is responsible for balance and hearing. Impaired function of this nerve can result in disequilibrium or vertigo with movement, which is a typical finding in vestibular dysfunction.

D. Inability to smell: Inability to smell is related to dysfunction of the olfactory nerve (cranial nerve I), not the vestibulocochlear nerve.

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A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse perform?

Correct Answer is ["A","D"]

Explanation

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Correct Answer is C

Explanation

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