During a routine eye examination, an older client reports decreased peripheral vision and is found to have elevated intraocular pressures. Ophthalmic drops are prescribed for primary open-angle glaucoma (POAG). Which intervention(s) should the nurse include in this client's plan of care? Select all that apply.

Review written and verbal instructions for a reduced sodium diet.

Teach strategies for aseptic administration of the eye drops.

Describe how the use of the eye drops will help improve peripheral vision.

Teach to apply pressure over the inner eye corner after eye drops.

Explain the need to continue eye drops for the rest of their life.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Reviewing written and verbal instructions for a reduced sodium diet is not directly related to the management of primary open-angle glaucoma (POAG). While a healthy diet can contribute to overall well-being, dietary sodium does not have a significant impact on intraocular pressure or glaucoma management. Therefore, this intervention does not directly address the client's primary condition of POAG.

Choice B reason: Teaching strategies for aseptic administration of the eye drops is a critical intervention for clients with POAG. Proper administration of ophthalmic drops is essential to avoid contamination and infection. Aseptic techniques include washing hands before administering the drops, avoiding touching the dropper tip to any surface (including the eye), and ensuring that the dropper cap is replaced tightly after use. These measures help maintain the sterility of the medication and prevent complications such as eye infections, which can exacerbate the client's condition.

Choice C reason: Describing how the use of the eye drops will help improve peripheral vision is not entirely accurate in the context of POAG. The primary goal of ophthalmic drops for POAG is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving the remaining vision. These drops do not typically improve peripheral vision that has already been lost. Educating the client with accurate information about the purpose and benefits of the drops helps set realistic expectations and encourages adherence to the treatment regimen.

Choice D reason: Teaching the client to apply pressure over the inner eye corner (punctal occlusion) after administering eye drops is an important intervention. Punctal occlusion helps prevent the medication from draining into the tear duct and being absorbed systemically. This technique increases the contact time of the medication with the eye, enhancing its effectiveness and reducing potential systemic side effects. Clients should be instructed to gently press the inner corner of the eye for a few minutes after instilling the drops to ensure maximum benefit.

Choice E reason: Explaining the need to continue eye drops for the rest of their life is essential for clients with POAG. Glaucoma is a chronic condition that requires lifelong management to control intraocular pressure and prevent progression of the disease. Discontinuing the medication can lead to elevated intraocular pressures and irreversible vision loss. Clients should understand the importance of adherence to their prescribed treatment regimen and the lifelong commitment to managing their condition to preserve their vision and quality of life.

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Correct Answer is B

Explanation

Choice A reason: Polyuria and excessive thirst are classic symptoms of diabetes insipidus and indicate the body's inability to retain water due to a lack of antidiuretic hormone (ADH). While these symptoms need to be managed, they are not immediately life-threatening compared to severe hypernatremia.

Choice B reason: A serum sodium level of 185 mEq/L (185 mmol/L) indicates severe hypernatremia, which is an immediate medical emergency. Severe hypernatremia can lead to neurological symptoms such as confusion, seizures, and even coma due to the osmotic shift of water out of brain cells. Immediate intervention is required to correct the sodium imbalance and prevent serious complications.

Choice C reason: An apical heart rate of 110 beats per minute is indicative of tachycardia, which can be associated with dehydration and the body's response to maintain cardiac output. While it is a concern, it does not take precedence over the need to address severe hypernatremia.

Choice D reason: Dry skin with inelastic turgor is a sign of dehydration, which is a common issue in diabetes insipidus due to excessive fluid loss. While this requires attention, it is not as immediately critical as addressing severe hypernatremia, which poses a direct and urgent threat to the client's neurological and overall health.

A. Temperature: 98.9°F B. Heart rate: 112 beats per minute C. Respirations: 28 breaths per minute D. Blood pressure: 130/86 mmHg E. Oxygen saturation: 88%

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

Temperature: 98.9°F

Neither Disease Process Nor Medication Use:
The temperature is within normal range and does not indicate an infection or other abnormality.

Heart Rate: 112 beats per minute

Disease Process:
The elevated heart rate (tachycardia) is most likely due to the asthma attack, which increases respiratory effort and oxygen demand. Anxiety from the attack could also contribute.

Respirations: 28 breaths per minute

Disease Process:
The elevated respiratory rate (tachypnea) is consistent with the asthma attack and respiratory distress, a hallmark of the disease process.

Blood Pressure: 130/86 mmHg

Neither Disease Process Nor Medication Use:
This value is slightly elevated but not significantly enough to be directly attributed to asthma or medication. It could be situational due to stress or anxiety.

Oxygen Saturation: 88%

Disease Process:
The low oxygen saturation is indicative of hypoxemia caused by bronchoconstriction and impaired gas exchange during the asthma attack.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?Reference Range: Sodium 136 to 145 mEq/L (136 to 145 mmol/L)

Correct Answer is B

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

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