An elderly client with macular degeneration tells the nurse that "all of a sudden" the television screen appeared distorted, with the colors all "wrong.". The nurse should do which of the following to help this client?

Question

1. Contact the physician for an immediate ophthalmological evaluation
2. Check the client's medications for side effects of vision changes
3. Ensure the client's safety by raising the bed rails
4. Talk with the client to assess for other hallucinations that might be occurring

Answer 1

1. Contact the physician for an immediate ophthalmological evaluation

Rationale:
The client with macular degeneration could be experiencing a sudden onset of exudative macular degeneration as evidenced by the client stating that the vision changes occurred suddenly and the colors on the television screen appear "wrong.". The nurse needs to contact the physician so that the client can be seen by an ophthalmologist. The client most likely is not experiencing a side effect of medications. Ensuring the client's safety is important; however, the nurse needs to do more than raising the bed rails. The client is not hallucinating.