A nurse provides education to a client recently diagnosed with macular degeneration. Which of the following statements made by the client requires reinforcement of education by the nurse?

"I will incorporate foods rich in vitamin C in my diet."

"I will receive injections into my eye."

"My vision will slowly be restored after I start using the eye drops."

"My vision will become progressively more blurry."

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is correct because incorporating foods rich in vitamin C in the diet can help prevent or delay macular degeneration. Vitamin C is an antioxidant that can protect the cells of the macula, which is the central part of the retina that is responsible for sharp and detailed vision, from oxidative stress and damage. The nurse should also advise the client to consume foods rich in other antioxidants, such as vitamin E, zinc, lutein, and zeaxanthin.

Choice B Reason: This is correct because receiving injections into the eye can help treat macular degeneration. Injections are a form of anti-vascular endothelial growth factor (anti-VEGF) therapy, which can block abnormal blood vessel growth and leakage in the macula that can cause vision loss. The nurse should explain to the client how often and how long they need to receive injections and what side effects or complications they may experience.

Choice C Reason: This is incorrect because vision will not be restored after using eye drops for macular degeneration. Eye drops are not a proven or effective treatment for macular degeneration, which is a chronic and progressive condition that causes irreversible vision loss. The nurse should reinforce education by informing the client that eye drops may only provide temporary relief of dryness or irritation, but they will not improve or restore vision.

Choice D Reason: This is correct because vision will become progressively more blurry with macular degeneration. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field. The nurse should educate the client on how to cope with vision loss and use adaptive devices, such as magnifiers, large-print books, or voice-activated technology.

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Correct Answer is ["B","D","E"]

Explanation

The correct answers are b, d, and e.

Choice A: Slurred speech.

Slurred speech can be associated with increased ICP due to the pressure effects on the brain areas responsible for speech production. However, it is not typically considered a late sign of increased ICP. It may occur earlier in the progression as the brain's ability to coordinate muscle movements is affected.

Choice B: Bradycardia with a bounding pulse.

Bradycardia with a bounding pulse is a classic sign of Cushing's triad, which is a late and ominous sign of significantly increased ICP. It indicates that the body is attempting to increase arterial blood pressure to overcome the increased ICP and maintain cerebral perfusion. The normal range for adult heart rate is 60-100 beats per minute.

Choice C: Confusion.

Confusion can be an early sign of increased ICP as it can indicate changes in cerebral function. However, it is not specifically a late sign of increased ICP. Early signs of increased ICP can include headache, nausea, and confusion, as the brain is initially responding to the pressure changes.

Choice D: Hypertension with an increasing pulse pressure.

Hypertension with an increasing pulse pressure is another component of Cushing's triad. It reflects the body's compensatory mechanism to preserve cerebral blood flow in the face of rising ICP. An increasing pulse pressure (the difference between systolic and diastolic blood pressure) is a late sign of increased ICP. Normal pulse pressure is typically 30-40 mm Hg.

Choice E: Nonreactive dilated pupils.

Nonreactive dilated pupils are a late sign of increased ICP and indicate pressure on the cranial nerves that control pupil size and reaction to light. This is a grave sign and often indicates impending brain herniation.

Choice F: Hypotension with a decreasing pulse pressure.

Hypotension with a decreasing pulse pressure is not typically associated with increased ICP. In fact, hypertension with a widening pulse pressure would be more indicative of increased ICP as part of Cushing's triad.

A. To administer medications and electrolytes B. To dilate the stomach as a presurgical preparation C. You will not be able to eat for several days D. To remove secretions and decompress your stomach

Correct Answer is D

Explanation

Choice A Reason: To administer medications and electrolytes is not the best reply for why the client will need the NG tube, because this is not the primary purpose of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Medications and electrolytes can be given through the IV route.

Choice B Reason: To dilate the stomach as a presurgical preparation is not the best reply for why the client will need the NG tube, because this is not a valid indication for the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Dilation of the stomach is not a goal of presurgical preparation, but rather an adverse effect of gastric obstruction.

Choice C Reason: You will not be able to eat for several days is not the best reply for why the client will need the NG tube, because this is not a complete or accurate explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. The client will not be able to eat for several days because of the NPO diet, which is necessary to rest the inflamed peritoneum and reduce the risk of complications.

Choice D Reason: To remove secretions and decompress your stomach is the best reply for why the client will need the NG tube, because this is a clear and correct explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration, which are common symptoms of acute peritonitis. By removing secretions and decompressing the stomach, the NG tube can reduce pain, inflammation, and infection in the abdominal cavity.

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A nurse provides education to a client recently diagnosed with macular degeneration. Which of the following statements made by the client requires reinforcement of education by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

Correct Answer is D

Explanation

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