The nurse is assessing a client who has a suspected retinal detachment. Which of the following client statements would be consistent with this diagnosis?
"I have intense pain above my eyebrow."
"It looked like a curtain was closing and I can only see bright flashes of light."
"My vision has a cloudy appearance."
"I'm having trouble with my peripheral vision."
The Correct Answer is B
A. "I have intense pain above my eyebrow.": Pain above the eyebrow may indicate conditions like sinusitis or angle-closure glaucoma, but retinal detachment typically presents without pain. Its symptoms are visual rather than sensory.
B. "It looked like a curtain was closing and I can only see bright flashes of light.": A sudden curtain-like shadow and flashes of light (photopsia) are classic signs of retinal detachment. These occur due to the retina pulling away from the back of the eye, disrupting vision.
C. "My vision has a cloudy appearance.": Cloudy vision is more commonly associated with cataracts or corneal issues. Retinal detachment usually presents with more acute and dramatic vision changes like darkening or loss of visual fields.
D. "I'm having trouble with my peripheral vision.": Peripheral vision loss can occur in retinal detachment but tends to follow the more distinctive symptoms like flashes and a curtain-like shadow. While relevant, it’s not diagnostically specific.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Providing ventilatory assistance: Myasthenic crisis involves severe muscle weakness, including the respiratory muscles, posing an immediate threat to airway and breathing. Ventilatory support is the highest priority to maintain oxygenation and prevent respiratory failure during this acute phase.
B. Facilitating ABG analysis: Arterial blood gas analysis is useful in evaluating respiratory status but does not take precedence over actually ensuring adequate ventilation. ABGs are diagnostic tools and should follow stabilization of the airway and breathing.
C. Suctioning secretions: Suctioning may be necessary, especially if the client has difficulty clearing secretions. However, suctioning is secondary to establishing ventilatory support, which addresses the root issue of respiratory insufficiency.
D. Administering tube feedings: Tube feeding is important for nutrition but is not an immediate concern in a myasthenic crisis. During respiratory compromise, maintaining a patent airway and supporting ventilation must come first before addressing nutritional needs.
Correct Answer is A
Explanation
A. Deviation of a great toe laterally: Hallux valgus, commonly known as a bunion, is characterized by the lateral deviation of the great toe toward the other toes. This deformity often leads to pain, swelling, and difficulty with footwear due to joint misalignment.
B. Abnormal flexion of the great toe: Abnormal flexion is more consistent with hammer toe or claw toe deformities. It does not describe the lateral displacement seen in hallux valgus.
C. An exaggerated arch of the foot: An exaggerated arch, or pes cavus, is a separate structural foot abnormality and is not associated with hallux valgus. It involves the shape of the foot, not the alignment of the toe.
D. Fusion of the toe joints: Fusion of toe joints may occur due to arthritis or surgical intervention but is not a typical feature of hallux valgus. Hallux valgus involves joint misalignment rather than joint fusion.
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