The nurse is examining the eyes of an elderly client using the ophthalmoscope. The vessels of the eyes are narrow and tapered in appearance. The nurse would correctly choose which of the following actions?
1. Document the findings as normal.
2. Assess the pupils to determine if they equal, round, reactive to light, and accommodation.
3. Inquire about any past history of hypertension.
4. Inquire about a history of diabetes.
3
Rationale 1: These are abnormal findings. Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension.
Rationale 2: The assessment of PERRLA is not necessary at this time. The nurse must obtain additional information about a previous diagnosis of hypertension.
Rationale 3: Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension.
Rationale 4: The vessels in diabetic retinopathy display small, red spots or creamy, round lesions that indicate punctate hemorrhages.
You might also like to view...
Which of the following nursing organizations is responsible for improving and advancing the quality of nursing education?
A) American Association of Colleges of Nursing B) National Council of State Boards of Nursing C) National League for Nursing D) National Student Nurses' Association
The nurse recognizes that which factor in a patient's history increases the risk for type 2 diabetes mellitus (DM)?
1. Body mass index of 23 2. Blood pressure of 130/80 3. Physical inactivity 4. Low waist-to-hip ratio
The novice nurse manager is discussing budgeting activities and variance reports with the experienced nurse manager. Which of the following comments by the novice nurse manager indicates that more education is needed?
1. "When I submit my monthly variance report, I need to provide a written explanation for each variance." 2. "I review my variances to determine the issues and identify whether there are ways that I can help prevent the variance from occurring." 3. "It is my responsibility to shelter my staff members from having to worry about this side of client care." 4. "Reviewing the budget and identifying variances is a great way to plan for next year's budget."
Compute the amount of medication that will be given to administer one dose of the following medication orders by using a proportion to obtain your answers.Round all parenteral administration orders that are over 1 mL to one decimal place. Round all parenteral administration orders under 1 mL to two decimal places. Do not include zeros at the end of decimal numbers
? The problems and drug orders are presented for practice only, and actual prescribed dosages will vary according to a patient's age, condition, reaction, additional medications, and other factors. Order: Solu-Medrol 75 mg IM b.i.d. Supply: Multidose vial of Solu-Medrol 500 mg Directions: Reconstitute with 8 mL of bacteriostatic water to yield 125 mg per 2 mL Give: ___________ mL Fill in the blank(s) with correct word