A nurse is caring for a client who has impaired speech.
Which of the following actions should the nurse take?

Choice A rationale:

When caring for a client at the end of life who is unresponsive, it is essential to maintain a compassionate and supportive presence. Continuing to talk to the client as if they are awake is a respectful and therapeutic approach. Even though the client may not respond verbally, they may still be able to hear and sense the presence of their loved ones and the healthcare team. This communication can provide comfort and reassurance.

Choice B rationale:

Limiting the client's visitors to one at a time is a reasonable consideration, as it can help reduce potential overwhelm and maintain a calm environment. However, this choice should be based on the client's and family's preferences. Some clients and families may prefer to have multiple visitors present for support and companionship during this difficult time.

Choice C rationale:

Avoiding touching the client is not recommended when caring for an unresponsive client at the end of life. Physical touch, when gentle and respectful, can convey comfort and support. The nurse should be sensitive to the client's preferences and the family's wishes regarding physical contact.

Choice D rationale:

Whispering when talking in the client's room is not necessary. While it's important to maintain a quiet and peaceful environment, speaking in a normal tone is appropriate. The client may still be able to hear and may find comfort in the familiar voices of their loved ones and the healthcare team. .

The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."

Choice A rationale:

• Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
• Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
• It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.

Choice B rationale:

• Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
• Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
• Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.

Choice C rationale:

• While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
• The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
• More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.

Choice D rationale:

• Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
• Other potential symptoms of diabetic retinopathy include:
  • Blurred vision
  • Floaters (dark specks or strings that move across the visual field)
  • Difficulty seeing at night or in low light
  • Loss of central vision
  • Distortion of colors
  • Blind spots