A nurse is collecting data from a client who has a suspected cataract. The nurse should collect data from which of the following areas to confirm the diagnosis?
The client’s tongue
The client’s eyelid
The lens of the client’s eye
The posterior pharynx of the client’s throat
The Correct Answer is C
Choice A Reason:
The client’s tongue is not relevant for diagnosing cataracts. Cataracts are an eye condition characterized by clouding of the lens, which affects vision. The tongue does not provide any information related to the presence of cataracts.
Choice B Reason:
The client’s eyelid is also not relevant for diagnosing cataracts. While the eyelid can be examined for other eye-related conditions, it does not provide information about the lens’s clarity or the presence of cataracts. Cataracts specifically affect the lens inside the eye.
Choice C Reason:
The lens of the client’s eye is the correct area to examine for diagnosing cataracts. Cataracts cause the lens to become cloudy, leading to symptoms such as blurred vision, difficulty seeing at night, and sensitivity to light. An eye examination, including a slit-lamp exam, allows the healthcare provider to see the lens and identify any cloudiness or opacities indicative of cataracts.
Choice D Reason:
The posterior pharynx of the client’s throat is not relevant for diagnosing cataracts. This area is examined for conditions related to the throat and respiratory system, not for eye conditions. Cataracts are diagnosed through an eye examination focusing on the lens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Administering intravenous fluids and pain management is the most appropriate initial intervention for a patient with sickle cell anemia presenting with severe pain, fever, and dehydration. Sickle cell crises often lead to severe pain due to vaso-occlusion, where sickled red blood cells block blood flow to various parts of the body. Intravenous fluids help to rehydrate the patient and reduce blood viscosity, which can alleviate the vaso-occlusive crisis. Pain management is crucial to provide relief and improve the patient’s comfort. This approach addresses the immediate symptoms and stabilizes the patient.
Choice B Reason:
Applying cold compresses to the painful areas is not recommended for patients with sickle cell anemia. Cold can cause vasoconstriction, which may worsen the vaso-occlusion and increase pain. Instead, warm compresses are often suggested to help dilate blood vessels and improve blood flow.
Choice C Reason:
Administering antibiotics immediately is not the primary intervention unless there is a clear indication of an infection. While fever can be a sign of infection, it can also occur due to the inflammatory response associated with a sickle cell crisis. The priority is to manage pain and dehydration first, and then evaluate the need for antibiotics based on clinical findings.
Choice D Reason:
Encouraging the patient to perform light exercise is not appropriate during an acute sickle cell crisis. Physical activity can increase oxygen demand and exacerbate the pain and vaso-occlusion. Rest and adequate hydration are more suitable to manage the crisis effectively.
Correct Answer is A
Explanation
Choice A Reason:
Administering IV levothyroxine is the priority intervention for a patient with myxedema coma. Myxedema coma is a severe form of hypothyroidism that requires immediate thyroid hormone replacement to correct the deficiency and stabilize the patient’s condition. Intravenous levothyroxine is preferred because it provides a rapid increase in thyroid hormone levels, which is crucial for reversing the life-threatening symptoms of myxedema coma, such as hypothermia, bradycardia, and altered mental status.
Choice B Reason:
Starting broad-spectrum antibiotics is not the primary intervention for myxedema coma. While infections can precipitate myxedema coma and should be treated if present, the immediate priority is to address the severe hypothyroidism with thyroid hormone replacement. Antibiotics may be administered if an infection is suspected or confirmed, but they do not directly address the underlying thyroid hormone deficiency.
Choice C Reason:
Administering corticosteroids immediately is important but not the highest priority. Corticosteroids are often given to patients with myxedema coma to treat potential adrenal insufficiency, which can coexist with severe hypothyroidism. However, the primary intervention remains the administration of thyroid hormone replacement to correct the hypothyroid state.
Choice D Reason:
Initiating fluid restriction is not appropriate for managing myxedema coma. Patients with myxedema coma often require careful fluid management to address potential hyponatremia and maintain hemodynamic stability. Fluid restriction is not a standard intervention for this condition and does not address the critical need for thyroid hormone replacement.
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