The nurse is examining the eyes of an elderly client using the ophthalmoscope. The vessels of the eyes are narrow and straight in appearance. The nurse would correctly choose which of the following actions?
1. Obtain an ophthalmology referral.
2. Inquire to determine if the client has any risk factors for glaucoma.
3. Inquire to determine if the client has a history of diabetes.
4. Document the findings as normal.
4
Rationale 1: Since this is a normal finding based on the client's age, the nurse does not need to attempt to obtain an ophthalmology referral.
Rationale 2: The client is not exhibiting signs of glaucoma. "Cupping" of the disc is a sign of glaucoma.
Rationale 3: Small red spots or creamy round lesions are punctate hemorrhages and exudate seen in diabetic retinopathy.
Rationale 4: Age-related changes in the eyes include the presence of narrower and straighter vessels, which should be documented as a normal finding.
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