A nurse is teaching a client who has macular degeneration about how to use an Amsler grid. Which of the following statements should the nurse include in the teaching?

"Note if you see any flashing bright lights on the grid."

"Check to see if the lines on the grid are blurry or distorted."

"Monitor for the lines on the grid to change in color or brightness."

"Watch for floating dark spots on the grid."

Answer and Explanation

The Correct Answer is B

A. "Note if you see any flashing bright lights on the grid." Flashing lights are not typically associated with macular degeneration. This symptom is more commonly associated with conditions like retinal detachment or migraine headaches.

B. "Check to see if the lines on the grid are blurry or distorted." This statement is correct. The Amsler grid is used to detect changes in central vision, which are common in macular degeneration. Patients with macular degeneration may perceive wavy or distorted lines instead of straight lines when looking at the grid, indicating central vision loss.

C. "Monitor for the lines on the grid to change in color or brightness." Changes in color or brightness of the lines on the grid are not typical features of macular degeneration. This statement does not accurately reflect the purpose of using an Amsler grid for macular degeneration.

D. "Watch for floating dark spots on the grid." Floating dark spots (floaters) are not typically associated with macular degeneration. Floaters are more commonly associated with conditions like posterior vitreous detachment or retinal detachment.

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Correct Answer is D

Explanation

A) Hypoxia and acidosis While hypoxia and acidosis are serious complications of shock, they are physiological rather than psychological outcomes. These conditions primarily affect the body's metabolic and respiratory functions, rather than mental health or behavior.

B) Hearing deficits and increased risk of glaucoma Hearing deficits and increased risk of glaucoma are potential complications associated with certain medical conditions or medications but are not directly related to the psychological outcomes of shock. These conditions affect sensory perception (hearing and vision) rather than mental health or behavior.

C) Bipolar behaviors and schizotypal behaviors Bipolar behaviors and schizotypal behaviors are manifestations of mood and psychotic disorders, respectively, and are not typical adverse outcomes of shock. While psychological disturbances can occur in critically ill patients, they are not commonly characterized by specific psychiatric diagnoses like bipolar or schizotypal behaviors.

D) Disorientation and depression Disorientation and depression are common adverse psychological outcomes experienced by patients who have spent an extended period in the intensive care unit (ICU) due to complications related to shock. Prolonged ICU stays, medical interventions, sedation, and physical discomfort can contribute to feelings of confusion, disorientation, and depression in patients. Therefore, it is essential for the nurse to educate the client about these potential psychological effects and provide appropriate support and resources to address them during the transition to the medical unit.

A. Ensuring that the client and their family are kept informed about the client's care B. Being aware of the client's wishes regarding care C. Scheduling periods of rest for the client D. Discussing the client's resting times with the family E. None F. None

Correct Answer is A

Explanation

Answer: A. Ensuring that the client and their family are kept informed about the client's care

Rationale:

A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.

B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.

C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.

D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.

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A nurse is teaching a client who has macular degeneration about how to use an Amsler grid. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit?

Correct Answer is D

Explanation

A nurse is providing care for a client who has multiple organ dysfunction syndrome (MODS). Which of the following actions is the priority when planning care for this client?

Correct Answer is A

Explanation

Rationale:

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