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 C
Explanation
A. Discontinuing the infusion of the solution may compromise the effectiveness of continuous bladder irrigation, which is typically indicated after TURP to prevent clot retention and ensure urinary drainage.
B. Manual irrigation of the catheter may disrupt the established irrigation system and lead to further complications. It is not the initial action to take in this situation.
C. Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation. Continued observation is necessary to ensure adequate drainage and identify any signs of complications.
D. Decreasing the flow rate may not address the underlying issue of clot retention and may not be appropriate without further assessment of the client's condition.
Correct Answer is B
Explanation
A. Internal bleeding may present with symptoms such as hypotension, tachycardia, and signs of blood loss, but it typically does not cause pitting edema or jugular venous distention.
B. Right-sided heart failure can cause systemic venous congestion, leading to pitting edema of the lower extremities and jugular venous distention due to increased central venous pressure.
C. Cardiac tamponade presents with Beck's triad (hypotension, distended neck veins, muffled heart sounds) and is typically more acute in onset compared to the gradual development of symptoms seen in right-sided heart failure.
D. Left ventricular dysfunction primarily causes symptoms of pulmonary congestion, such as dyspnea, orthopnea, and crackles, rather than pitting edema and jugular venous distention.
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