Patient Data
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential condition: Retinopathy
Actions to take: Orient the client to the environment; Call for an ophthalmological exam
Parameters to monitor: Blood glucose; Visual acuity
Rationale:
Based on the patient data provided, the client is most likely experiencing retinopathy, particularly diabetic retinopathy, which is a common complication of diabetes and can lead to progressive vision loss. The elevated HBA1C level indicates poor blood glucose control, which can contribute to the worsening of this condition.
The nurse should call for an ophthalmological exam to confirm the diagnosis and assess the extent of retinal damage. Additionally, orienting the client to the environment is important to ensure safety due to the vision impairment. Monitoring the client's blood glucose levels is crucial for managing his diabetes and potentially stabilizing or improving the retinopathy.
Visual acuity should also be monitored to track any changes in vision and the effectiveness of interventions. It is essential to manage the underlying diabetes effectively to prevent further progression of retinopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
B. Providing frequent mouth care is important for oral hygiene but may not be as critical as ensuring a patent airway during seizures.
C. Keeping the room at a comfortable temperature is important for overall comfort but is not the most essential intervention during seizure activity.
D. Maintaining the client in a semi-Fowler's position may help with ventilation and drainage but is not as crucial as ensuring airway patency.
Correct Answer is C
Explanation
A. Bronze pigmentation is not typically associated with compromised peripheral arterial circulation but may be seen in conditions like hemochromatosis.
B. Lower leg edema is more commonly associated with venous insufficiency rather than compromised arterial circulation.
C. Uneven hair distribution, such as decreased hair growth on the lower extremity, is indicative of compromised peripheral arterial circulation due to reduced blood flow to the area.
D. Bounding peripheral pulse is not typically associated with compromised peripheral arterial circulation but may indicate increased stroke volume or arterial stiffness.
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