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A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy.
Which of the following statements should the nurse make to the client?

A.

"Clouding of the lens is a manifestation of diabetic retinopathy.”.

B.

"It is caused by an increase in intraocular pressure.”.

C.

"Have an eye exam every 2 years.”.

D.

"Seeing spots is a manifestation of diabetic retinopathy.”.

Answer and Explanation

The Correct Answer is D

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


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Related Questions

Correct Answer is A

Explanation

Choice A rationale:

Prolonged grief is characterized by an extended period of mourning and difficulty in accepting the loss. This type of grief is often associated with intense emotional pain and can last for an extended period, beyond what is considered a normal grieving process. In this scenario, the client's inability to accept the loss of their partner after 3 years is indicative of prolonged grief.

Choice B rationale:

Uncomplicated grief refers to a normal grieving process that follows a loss. It typically involves feelings of sadness, anger, and sorrow, but the individual can eventually accept the loss and continue with their life. The client in the scenario is experiencing prolonged and complicated grief, which does not fit the definition of uncomplicated grief.

Choice C rationale:

Anticipatory grief occurs when individuals start grieving before the actual loss takes place, often seen in situations where a loved one has a terminal illness, and the family begins to mourn the eventual loss. The client in the scenario is not experiencing anticipatory grief, as the loss has already occurred.

Choice D rationale:

Disenfranchised grief refers to grief that is not openly acknowledged or socially supported. It occurs when an individual's loss is not recognized or validated by others, such as in the case of the loss of a same-sex partner, a pet, or a non-traditional relationship. In this scenario, the client's grief is not disenfranchised; it is prolonged and complicated.

Correct Answer is D

Explanation

Choice A rationale:

Full thickness skin loss with visible bone. This choice does not align with the description of a stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness skin loss, but they do not involve visible bone. This description corresponds to a more severe stage of pressure injury.

Choice B rationale:

Intact skin with localized erythema. This choice describes a normal skin condition with localized redness (erythema) but does not indicate the presence of a pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, which means there is a break in the skin integrity.

Choice C rationale:

Full thickness skin loss with visible adipose tissue. This description is more in line with a stage 3 pressure injury, not a stage 2 injury. In stage 3, there is full-thickness skin loss, and adipose tissue may become visible in the wound bed. However, in stage 2, the skin loss is partial-thickness, and the wound bed typically contains red tissue.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed. This choice is the correct description of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss with the presence of red or pink tissue in the wound bed. It signifies damage to the epidermis and possibly the dermis. .

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