A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?

Rationale:

A. Clarify the source of the referral: Before taking any action, the nurse must first clarify the referral source to understand why the visit is needed, the client’s health status, and any specific concerns or priorities. This ensures the nurse has accurate and complete information to plan the visit safely and effectively.

B. Contact the family by phone: While contacting the family is necessary to arrange the visit, it should occur only after the nurse understands the purpose of the referral and any special considerations to communicate relevant information.

C. Implement the nursing process: Implementing the nursing process requires assessment and planning. The nurse cannot proceed to intervention without first obtaining information about the referral and preparing appropriately.

D. Schedule a time for the home visit: Scheduling is important for logistics, but it should occur after clarifying the referral and understanding the family’s needs to ensure the visit is purposeful and safe.

Rationale:

A. Strabismus: Strabismus, or misalignment of the eyes, is not a known adverse effect of timolol. Timolol primarily affects intraocular pressure and systemic cardiovascular parameters rather than eye muscle alignment.

B. Bradycardia: Timolol is a nonselective beta-adrenergic blocker that can be absorbed systemically even when administered as eye drops. One potential systemic adverse effect is bradycardia, as the medication can reduce heart rate and cardiac output, particularly in clients with preexisting heart conditions.

C. Conjunctivitis: While eye irritation or mild stinging can occur with timolol, conjunctivitis is not a typical adverse effect. Instructing clients to monitor for more common ocular side effects, such as burning or discomfort, is appropriate.

D. Hyperglycemia: Timolol does not typically cause hyperglycemia. Beta-blockers can sometimes mask hypoglycemia symptoms in diabetic clients but are not associated with raising blood glucose levels directly.