The nurse is caring for a patient diagnosed with Multiple Sclerosis (MS) who is complaining of diplopia. Which intervention would be appropriate for the patient with this problem?
Encourage the use of sunglasses when outside.
Assess for conjunctival bleeding.
Alternate the use of an eye patch on each eye.
Apply cool compresses for pain relief
The Correct Answer is C
A. Encourage the use of sunglasses when outside: Sunglasses are useful for reducing glare and light sensitivity, but they do not address the underlying cause of diplopia (double vision) in Multiple Sclerosis (MS). Diplopia is often due to neurological damage affecting the eye muscles or nerve pathways, not from light sensitivity.
B. Assess for conjunctival bleeding: Conjunctival bleeding (bleeding under the eye's clear surface) is not related to diplopia. Diplopia in MS is caused by problems with the nerves or muscles controlling eye movement, and assessing for conjunctival bleeding would not help in managing the double vision.
C. Alternate the use of an eye patch on each eye: Diplopia in MS is commonly caused by eye misalignment due to nerve damage. Using an eye patch on one eye at a time can temporarily help by blocking vision in one eye, allowing the brain to focus and alleviating the perception of double vision. Alternating the patch between eyes is a common strategy to manage diplopia while treating the underlying neurological issues.
D. Apply cool compresses for pain relief: Cool compresses might help with general eye discomfort, but they do not directly address diplopia. Diplopia due to MS is usually caused by muscle or nerve issues rather than discomfort that could be relieved by cool compresses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decrease in blood pressure: Nitroglycerin can cause vasodilation, leading to a decrease in blood pressure. However, the goal of administering nitroglycerin during an acute myocardial infarction (MI) is not primarily to lower blood pressure, but to improve oxygen supply to the heart and relieve pain. A decrease in blood pressure may occur as a side effect but is not the primary indication for its use.
B. Decrease in cardiac dysrhythmias: While nitroglycerin may help reduce myocardial oxygen demand, it is not specifically aimed at treating or preventing cardiac dysrhythmias. The primary action of nitroglycerin is to relieve chest pain by vasodilation and improving blood flow to the heart muscle.
C. Relief of chest pain: The primary effect of nitroglycerin in the setting of an acute MI is to relieve chest pain (angina). It works by dilating coronary arteries and improving blood flow to the heart muscle, thus reducing ischemia and relieving pain.
D. Decrease in heart rate: Nitroglycerin may have a secondary effect of reducing heart rate due to a reduction in preload and afterload, but this is not the primary objective. Nitroglycerin’s main goal is to relieve chest pain by improving oxygen supply to the heart muscle.
Correct Answer is B
Explanation
A. Respiratory rate 26, irregular: Pt reports no shortness of breath or chills: An irregular respiratory rate may indicate some underlying issues. Although the patient reports no shortness of breath or chills, an irregular respiratory rate could signal a cardiac issue or a lingering effect of the infection. It’s not sufficient to confirm the effectiveness of antibiotic therapy.
B. Temp-99F (37.2°C); Lungs clear bilaterally; Pulse ox 98% on 2 liters oxygen; productive cough: clear to yellow sputum: This indicates improvement in the patient’s condition:
A temperature of 99°F is a mild, controlled fever, which is common in the recovery phase but suggests a reduction from higher fever associated with infection.
Clear lungs bilaterally are a good sign, indicating that there is no longer significant consolidation or inflammation in the lungs.
Pulse oximetry of 98% on 2 liters of oxygen is a positive sign that the oxygenation is improving.
Productive cough with yellow sputum indicates that the body is still clearing the infection, but it is a typical sign of recovery as the patient produces sputum.
C. Pt reports fatigue: Resp rate 28 on 2 liters oxygen: audible expiratory wheezes: This is concerning. The patient is still experiencing fatigue and audible wheezes, which may indicate unresolved inflammation or bronchoconstriction. The respiratory rate of 28, while slightly elevated, also suggests ongoing respiratory stress. This could indicate that the infection is not fully controlled.
D. Cough: white sputum: Temp 99F (37.2°C); Pulse ox 96%: This is somewhat positive, but it lacks the detail of clear lungs or other more definitive signs of improvement. The white sputum could suggest that the infection is resolving, but there is still some degree of infection or inflammation. Pulse ox at 96% is acceptable, but the lack of clear lungs bilaterally makes it less ideal.
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