A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

Keep objects in the client's room in the same place.

Approach the client from the side.

Ensure there is high-wattage lighting in the client's room.

Allow extra time for the client to perform tasks.

Touch the client gently to announce presence.

Answer and Explanation

Correct Answer : A,C,D

A.   Keeping objects in the same place help maintain a safe environment and independence for a client with vision loss.
B.   When caring for a client with vision loss, the nurse should avoid approaching the client from the side since it may startle them.
C.   Providing high-wattage lighting can improve visibility for clients with partial vision loss. Adequate lighting reduces shadows and enhances contrast, making it easier for the client to see their surroundings

D. Allowing extra time for tasks helps orient them to the nurse's presence and facilitates communication.
E. While gentle touch can be a way to announce presence, it is better to verbally announce oneself first to avoid startling the client, particularly if they are not expecting contact.

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Correct Answer is A

Explanation

A. Phenytoin should be taken with food to minimize gastrointestinal side effects and enhance absorption.
B. There is no specific requirement to limit foods containing vitamin D while taking phenytoin.

C. Phenytoin does not typically interfere with folic acid metabolism, so there is no need to limit foods containing folic acid.
D. Phenytoin should not be taken with antacids, as they can decrease its absorption.

A. BP 150/92 mm Hg B. Flushed face C. Pulse rate 100/min D. Negative clonus

Correct Answer is D

Explanation

A. A blood pressure reading of 150/92 mm Hg is indicative of hypertension, a symptom of preeclampsia, but it is not a therapeutic effect of magnesium sulfate.
B. A flushed face is not a therapeutic effect of magnesium sulfate and may indicate adverse effects such as magnesium toxicity.
C. A pulse rate of 100/min is within the normal range and is not a specific therapeutic effect of magnesium sulfate.
D. Negative clonus, assessed by dorsiflexing the client's foot and observing for absence of rhythmic oscillations or beats, indicates a therapeutic level of muscle relaxation provided by magnesium sulfate to prevent seizures in clients with preeclampsia

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Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to an older adult client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV Infusion. For which of the following therapeutic effects should the nurse monitor the client?

Correct Answer is D

Explanation

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