The nurse plans the care of an older female resident of a nursing home who has experienced a sudden deterioration in visual acuity. Which intervention should the nurse complete first?
a. Prevent behavioral and social decline.
b. Tell her to hold onto the rails during am-bulation.
c. Examine her mood and functional status.
d. Use problem solving involving the resi-dent.
C
The most important intervention for the nurse to complete first is to assess the impact of the vis-ual impairment on the resident's quality of life, mood, and functional ability. The resulting as-sessment data will provide the basis for solving new problems caused by the loss of vision and finding compensatory mechanisms for the resident. Preventing decline can be a goal in the overall plan of care for this resident, but that cannot be determined until the assessment is complete. Telling her to hold onto rails during ambulation is a potential nursing intervention for patient teaching; however, in problem solving, a different compensatory solution can be developed, based on the assessment. Problem solving takes place after a complete assessment.
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