A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Nystagmus

Astigmatism

Loss of central vision

Client reports sharp pain

Answer and Explanation

The Correct Answer is C

Rationale:

A. Nystagmus: Nystagmus is characterized by involuntary eye movements and is typically associated with vestibular disorders, multiple sclerosis, or congenital conditions. It is not a symptom of macular degeneration, which primarily affects the retina.

B. Astigmatism: Astigmatism is a refractive error due to an irregularly shaped cornea or lens. It is unrelated to macular degeneration, which involves degeneration of the macula—the part of the retina responsible for sharp central vision.

C. Loss of central vision: Macular degeneration leads to progressive deterioration of the macula, resulting in blurred or complete loss of central vision while peripheral vision remains intact. This is a hallmark symptom and significantly affects activities like reading and recognizing faces.

D. Client reports sharp pain: Macular degeneration does not typically cause pain. It is a painless condition, and the presence of sharp eye pain may suggest another acute ocular issue such as glaucoma or injury, not related to macular changes.

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Free Nursing Study Resources

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

Explanation

Rationale:

• 3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and insomnia: These symptoms are consistent with hypermetabolic activity seen in hyperthyroidism, particularly Graves’ disease, and require follow-up and management to prevent complications like thyroid storm.

• Last menstrual period was 3 months ago: Amenorrhea can occur due to hormonal imbalance caused by elevated thyroid hormones. This finding indicates endocrine dysfunction and should be investigated further.

• Skin is warm and moist. Exophthalmos noted, goiter visualized on neck: These are classic physical signs of Graves’ disease, an autoimmune hyperthyroid condition. The exophthalmos (protruding eyes) and goiter (thyroid enlargement) are abnormal and require follow-up.

• Client's partner reports that the client is irritable and anxious lately: Mood changes, such as irritability and anxiety, are common in hyperthyroidism and may affect the client’s quality of life and safety. This finding warrants further psychological and endocrine evaluation.

A. Wipe from the outer to the inner canthus after administering the crops. B. Position the child side-lying on the bed before administering the drops. C. Apply pressure to the lacrimal punctum after administering the drops. D. Flush the eye with formal saline solution before administering the drops.

Correct Answer is C

Explanation

Rationale:

A. Wipe from the outer to the inner canthus after administering the drops: The correct technique is to wipe from the inner to the outer canthus to avoid introducing pathogens into the lacrimal system. Wiping in the wrong direction increases the risk of eye infections.

B. Position the child side-lying on the bed before administering the drops: Eye drops should be administered with the child in a supine or slightly reclined position. Side-lying positioning is more appropriate for ear drops and does not allow proper exposure of the conjunctival sac.

C. Apply pressure to the lacrimal punctum after administering the drops: Pressing the lacrimal punctum (inner corner of the eye) helps prevent systemic absorption of the medication by occluding the tear duct. This increases local efficacy and reduces the risk of systemic side effects, which is especially important in children.

D. Flush the eye with formal saline solution before administering the drops: Flushing with formal saline is unnecessary unless there is debris or discharge. Routine eye drop administration does not require pre-flushing..

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A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in a provider's clinic. Exhibits Select the findings that require follow-up.

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

Explanation

A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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