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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?

A.

Avoid frequent eye pressure measurements.

B.

Maintain prescribed eye drop regimen.

C.

Wear prescription glasses.

D.

Eat a diet high in carotene.

Answer and Explanation

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 B

Explanation

A. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.

B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.

C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.

D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.

Correct Answer is D

Explanation

A. Joint pain is a common symptom of systemic lupus erythematosus (SLE) and, while it may indicate an exacerbation of the disease, it is not the most critical finding to report.

B. A low-grade fever can signify an infection or increased disease activity but is generally not as urgent as changes in renal function or systemic involvement.

C. Muscle atrophy is a concern over time but does not pose an immediate threat to the client’s health compared to acute changes in kidney function.

D. Hematuria is significant in SLE as it can indicate renal involvement, such as lupus nephritis, which can lead to severe complications. This finding requires prompt reporting and assessment to prevent further renal damage and manage potential complications effectively.

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