The nurse is caring for a client who is legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate?

Promote the client's hope for recovery.

Encourage the client to focus on use of other senses.

Assess and promote the client's coping skills.

Emphasize that lifestyle will be unchanged.

Answer and Explanation

The Correct Answer is C

A. Macular degeneration is progressive and irreversible, so promoting hope for recovery may be unrealistic and could lead to frustration or false expectations.

B. While encouraging the use of other senses may help with adaptation, this does not directly address the client’s psychosocial needs.

C. Assessing and supporting the client’s coping skills is essential in helping them adjust to permanent vision loss, maintain independence, and prevent depression or anxiety. Psychosocial interventions are critical in chronic, irreversible conditions.

D. Blindness will change the client’s lifestyle, so emphasizing that nothing will change is misleading and could hinder realistic adjustment.

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Correct Answer is C

Explanation

A. Nausea with fatty foods is expected in cholecystitis and does not indicate immediate life-threatening complications.

B. A productive cough in bronchitis requires monitoring and supportive care, but it is not the most urgent concern.

C. Rigid abdomen and fever in appendicitis indicate peritonitis, a surgical emergency. This client is at highest risk for sepsis and requires immediate assessment and intervention.

D. Urine output of 30 mL/hour is low but not immediately life-threatening compared to peritonitis; it requires monitoring and possible intervention but is less urgent.

A. The client has acute pain with movement B. The client is not taking deep breaths C. Bile-colored fluid in the Jackson Pratt drain. D. Rigidity of the abdomen

Correct Answer is D

Explanation

A. Pain is an expected finding after surgery, especially with movement. Pain should be managed, but it does not require immediate provider notification unless unrelieved or worsening significantly.

B. Shallow breathing is often due to pain after abdominal surgery. While this increases the risk of atelectasis or pneumonia, it is not the most urgent concern. The nurse should encourage deep breathing and incentive spirometry.

C. Bile-colored fluid in the drain may occur following gallbladder surgery and should be monitored. While excessive drainage or sudden increases may need to be reported, a small amount of bile-stained drainage is not unexpected.

D. Abdominal rigidity is a sign of peritonitis or intra-abdominal bleeding, both of which are life-threatening complications requiring immediate intervention. This assessment finding is a surgical emergency.

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The nurse is caring for a client who is legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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