In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?
Mild headaches
Cloudiness that worsens at night
Severe eye pain
Mild eye pain
The Correct Answer is C
Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.
Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.
Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.
Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Pyridostigmine is used to treat myasthenia gravis, not for preventing Addisonian crisis in patients undergoing adrenalectomy. It is not related to adrenal hormone replacement.
Choice B reason: Tensilon (edrophonium) is used in the diagnosis of myasthenia gravis and is not relevant for managing adrenal insufficiency or preventing Addisonian crisis.
Choice C reason: Hydrocortisone intravenously is the correct choice for preventing Addisonian crisis in a client scheduled for adrenalectomy. Hydrocortisone provides the necessary corticosteroid replacement to manage the deficiency of adrenal hormones during and after surgery.
Choice D reason: Spironolactone is a potassium-sparing diuretic used to treat conditions like heart failure and hypertension. It is not used for preventing Addisonian crisis or managing adrenal insufficiency.
Correct Answer is C
Explanation
Choice A reason: Limiting fluid intake in the evening may reduce the need to urinate at night but does not address the client's fear of falling. It is more important to provide a safer alternative for nighttime voiding.
Choice B reason: Putting the side rails up and instructing the client to call the nurse before voiding may help, but it does not provide the most immediate and practical solution. A bedside commode offers a safer and more accessible option.
Choice C reason: Obtaining a bedside commode for the client's use directly addresses the client's concern about falling. It allows the client to void safely without having to walk to the bathroom at night, reducing the risk of falls.
Choice D reason: Leaving a nightlight on in the room can help improve visibility but does not completely eliminate the risk of falling. A bedside commode is a more effective solution.
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