The nurse is assessing a client's eyes during a comprehensive health assessment. Which assessment finding would require immediate intervention?

1. Acute glaucoma.
2. Blepharitis.
3. Periorbital edema.
4. Anisocoria.


Correct Answer: 1
Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage. Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention. Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention. Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease.

Nursing

You might also like to view...

A 56 -year-old man is admitted to the emergency room with an acute attack of diverticulitis. The patient has a temperature of 102 ° F, and has an elevated white count. Which assessment would alert the nurse to impending septic shock?

a. Chest pain b. Seizure c. Tachycardia d. Massive diarrhea

Nursing

A client experiencing severe chest pain from a pulmonary embolism has been medicated for pain but appears anxious and restless. The additional nursing measure that most likely would assist the client in dealing with fear is

a. asking the client not to focus on the pain. b. explaining the monitoring devices to the client. c. reassuring the client the pain medication will work soon. d. remaining at the bedside with the client.

Nursing

Your 65-year-old client has a history of chronic obstructive pulmonary disease and is now in acute congestive heart failure. The client has extreme dyspnea and is only able to ambulate from a recliner to the bathroom and back

Which nursing diagnosis would be most appropriate? 1. Impaired physical mobility 2. Disturbed sensory/perceptual 3. Activity intolerance 4. Impaired skin integrity

Nursing

A client comes to the emergency department with a fever of 104° F. What will the best plan by the nurse include?

1. Plan to obtain liver and renal function tests. 2. Plan to obtain a complete blood count (CBC) test. 3. Plan to obtain a sterile urine specimen. 4. Plan to obtain blood for culture and sensitivity.

Nursing