A nurse is performing a tonometry test on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23 mm Hg. What should the nurse's initial action be?
Note the time of day the test was done.
Apply normal saline drops.
Instruct the client to sleep with the head of the bed flat.
Contact the primary health care provider.
The Correct Answer is D
A. While noting the time of day is important for documentation, it does not address the immediate concern of elevated intraocular pressure (IOP).
B. Applying normal saline drops is not indicated in the immediate management of elevated IOP in glaucoma; it does not directly affect IOP levels.
C. Instructing the client to sleep with the head of the bed flat is not advisable, as elevated head positions may help decrease IOP.
D. An IOP of 23 mm Hg is above the normal range (10-21 mm Hg) and indicates potential glaucoma. Therefore, contacting the primary health care provider for further evaluation and treatment is the most appropriate initial action.
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Correct Answer is ["A","B","D"]
Explanation
A. Hypertension can occur due to autonomic dysreflexia, especially in clients with cervical spinal cord injuries, as they may have exaggerated sympathetic responses.
B. A weakened gag reflex can result from cranial nerve involvement due to the cervical spinal cord injury, impacting the client's ability to protect their airway.
C. Absence of bowel sounds may indicate bowel immobility or dysfunction; however, it is not a direct complication of a cervical spinal cord injury.
D. Bradycardia is a common finding in cervical spinal cord injuries due to impaired sympathetic nervous system function, leading to decreased heart rate.
E. Tachycardia is less common in cervical injuries and is typically associated with lower injuries in the spinal cord.
Correct Answer is A
Explanation
A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.