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 B
Explanation
A. restatement. Restatement involves repeating the patient’s words exactly, while here, the nurse is rephrasing the sentiment.
B. reflection. Reflection focuses on the patient’s feelings or experiences by paraphrasing their statement, helping the patient explore their feelings, which the nurse is doing here.
C. open-ended question. An open-ended question would be broad, allowing the patient to provide more information. This response is a restatement, not a question.
D. offering self. Offering self involves expressing a willingness to stay or support the patient, which is not demonstrated here.
Correct Answer is B
Explanation
A. Discontinuing the infusion may lead to increased clotting and potential obstruction of the catheter. Continuous bladder irrigation is essential to keep the bladder clear of clots and debris following surgery.
B. Manually irrigating the catheter can help clear any clots that may be obstructing the catheter, ensuring adequate drainage and preventing complications such as bladder distention or retention. This is the most immediate and appropriate action to take in response to the presence of clots.
C. Monitoring catheter drainage is important; however, it does not address the potential issue of clots obstructing the flow of urine, which is the priority concern in this scenario.
D. Decreasing the flow rate may not be beneficial and could lead to inadequate irrigation of the bladder, which could exacerbate clot formation and urinary retention.