The nurse is developing a teaching plan for the client with glaucoma.
Which of the following instructions would the nurse include in the plan of care?

Decrease fluids to reduce intraocular pressure.

Eye drops will be needed lifelong.

Limit the amount of salt in the diet.

Avoid activities that overuse the eyes.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Fluid intake does not directly impact intraocular pressure. Management of glaucoma focuses on medications like eye drops and surgical interventions rather than restricting fluid intake.

Choice B rationale

Glaucoma treatments, including eye drops, aim to manage intraocular pressure. These medications are required lifelong to prevent optic nerve damage and preserve vision.

Choice C rationale

Excess salt impacts systemic blood pressure but does not directly influence intraocular pressure. Glaucoma management targets ocular pressure, not dietary sodium reduction.

Choice D rationale

Avoiding eye overuse may reduce strain but does not address intraocular pressure. Effective glaucoma treatment relies on pharmacological or surgical measures rather than activity limitation.

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Correct Answer is A

Explanation

Choice A rationale

Extremely high systolic BP (220 mmHg), bradycardia (HR 30), and altered respirations (RR 6) suggest Cushing's triad, a hallmark of increased ICP due to severe brain injury.

Choice B rationale

Hypothermia (T92.5°F) and hypotension (BP 90/64) do not indicate increased ICP but may result from shock or hypothermic conditions affecting autonomic responses.

Choice C rationale

Hyperthermia (T103.1°F) and tachycardia (HR 132) are commonly seen in infection or hypermetabolic states, not directly pointing to raised ICP.

Choice D rationale

Mild hypertension (BP 200/94) with normal HR (90) and RR (18) does not fit the classic signs of increased ICP like Cushing's triad.

A. Elevate the head of the bed 30-45 degrees. B. Perform serial neurologic assessments while hospitalized. C. Suction frequently to prevent development of pneumonia. D. Administer sedatives/pain medications per orders. E. Stimulate the patient with TV, music, lights, and family at bedside.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Elevating the head 30-45 degrees aids in venous drainage and reduces intracranial pressure. It also prevents cerebral edema by improving cerebrospinal fluid outflow without compromising cerebral perfusion.

Choice B rationale

Serial neurological assessments help monitor for changes in intracranial pressure, enabling early intervention. They ensure timely recognition of symptoms indicating worsening pressure or neurological deterioration.

Choice C rationale

Frequent suctioning increases intracranial pressure due to stimulation of the vagus nerve, leading to coughing or gagging. It can also induce hypoxia, further exacerbating intracranial pressure.

Choice D rationale

Administering sedatives and pain medications reduces cerebral metabolic rate and sympathetic stimulation, which in turn prevents spikes in intracranial pressure. It also helps prevent agitation and discomfort in the patient.

Choice E rationale

Stimulating the patient with TV, music, lights, and family increases sensory input, which can elevate intracranial pressure. Overstimulation can cause agitation, raising intracranial pressure further.

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The nurse is developing a teaching plan for the client with glaucoma.Which of the following instructions would the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Explanation

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The nurse is developing a teaching plan for the client with glaucoma.
Which of the following instructions would the nurse include in the plan of care?