An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
Avoid frequent eye pressure measurements.
Maintain prescribed eye drop regimen.
Wear prescription glasses.
Eat a diet high in carotene.
The Correct Answer is B
A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.
B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.
C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.
D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.
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Correct Answer is C
Explanation
A. "Take the vital signs on all the patients in the lounge and tell me whether there are problems." This instruction is vague and lacks specific information about what "problems" to look for, which may lead to inconsistent reporting.
B. "Do the morning care first on the patients in 205 and 206 who can't get out of bed." This instruction is clear, but it does not specify important details like the specific type of care expected or additional needs.
C. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed." This instruction is specific, clear, and provides a follow-up action (check her feet) which is necessary. It allows the nursing assistant to understand exactly what to do and when.
D. "You take care of all the patients in 205 and 206. Let me know how you're doing and whether you need any help." This instruction lacks specificity and does not outline clear tasks or expectations, which may lead to confusion.
Correct Answer is A
Explanation
A. Monitoring for occult blood in urine and stool is crucial in clients with low platelet counts to detect any potential bleeding early, as they are at increased risk of bleeding due to thrombocytopenia.
B. Using a large gauge catheter may be necessary for some procedures, but it is not the priority intervention regarding the client’s current state and platelet count.
C. Removing cold and frozen foods from dietary trays does not directly address the critical concern of bleeding associated with low platelet levels.
D. While protecting bruised areas is important, it is secondary to monitoring for active bleeding, which is more critical at this stage.