A nurse is planning care for a client who has vision loss
A nurse is planning care for a client who has vision loss
A nurse is planning care for a client who has vision loss. B. The client is scheduled for discharge to his home where he lives alone. Loss of Depth perception D. Get more information about what Medicare does and does not cover related to vision services and supplies, and some resources that can help you pay for A client who sustained a gunshot wound has symptoms below the level of T-12 of ipsilateral motor paralysis, loss of proprioception and vibratory sense, and contralateral loss of pain and temperature sensation. Administer furosemide b. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. Which of the following interventions should the nurse include in the plan? A nurse is assisting with the plan of care for a client who is postoperative following repair of a detached retina. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Reading glasses may become necessary for close work. What symptoms is the nurse likely to find during the initial assessment? A) Loss of hearing, tinnitus, and vertigo B) Loss of vision, change in mental status, and hyperthermia C) Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer a soapsuds enema to an adult client. Following assessment of a patient's needs, the next stage is to ‘plan care’ to address the actual and potential problems that have been identified. Low vision refers to visual impairment that cannot be corrected by standard eyeglasses, medical or RN, BSN, PHN. , The older adult This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. After the age of 40, the risk of eye diseases and vision problems increases drastically. Cover exposed extension cords with throw rugs. c) Tilt the client's head backwards when he swallows. The primary nursing care plan goals for clients with stroke depend on the phase of CVA the client is in. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. . Avoid salty foods Study with Quizlet and memorize flashcards containing terms like What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)? 1. Administer eye drops as needed, A nurse is planning The home care nurse is preparing to visit a client who has undergone renal transplantation. assign a Extending the role of the ophthalmic nurse practitioner can promote delivery of a more effective health care service and reduce waiting times. C. An effective report should: Include significant Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is immobile and requires continuous mitten restraints. For patients who have both dementia and hearing loss, hearing aids can be useful to improve communication, and have an overall positive impact on care (Gregory et al, 2017). The nurse is preparing a nursing care plan for a 2-year-old child with hearing impairment. O. Eyestrain and headache with close work. Which strategy is effective in enhancing a patient's impaired vision? View Planning Home Safety for an Older Adult Client Who Has Vision Loss. Nursing Diagnosis: Disturbed Sensory Perception (Visual) related to the deterioration of macula as evidenced by verbal complaint of vision Use this nursing care plan and management guide to provide care for patients with macular degeneration. monitoring for pain and eye redness D. Which of the following should the nurse include in the teaching, A nurse is admitting a client who has a partial hearing loss. Lack of awareness, A nurse is caring for a client who Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition (PPN). Which of the following findings should the nurse expect?, Which of the following findings require immediate follow-up by the nurse? (Select all that apply. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in The client is grieving a significant loss and needs to be allowed to work through the issues. , The nurse is planning care for a client with right-sided weakness and aphasia from a transient ischemic attack (TIA). Which of the following interventions should the nurse include in the plan?, A nurse is assessing a client who has fluid volume deficit. b. Final answer: When caring for a client with vision loss, interventions such as providing small-handled utensils, arranging food in a consistent pattern, and thickening liquids can help with feeding. When caring for someone who has vision problems: say your name when you arrive; use a clear natural voice Question: a nurse is caring for a client who has vision loss. receiver b. An older adult client has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the client for recent changes in visual acuity, the client states that the lines on Allow expression of feelings about loss and possibility of loss of vision. which of the following interventions should the nurse include in the plan of care to assist the client with "A nurse is planning care for a client who has vision loss. Acute pain is not a problem that needs to be addressed when planning care for a client with MS. Includes step-by-step instructions showing how to implement A home health nurse is planning care for an older client who has impaired vision. The client should drink with a straw and cut foods into small pieces to facilitate chewing. The nurse should identify that which of the following findings indicates increasing intracranial pressure? a. Which of the following interventions should the nurse include in the plan of care? Answer Choices: Tell the client which food she should eat first Provide small-handled utensils for the client Thicken The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. Study with Quizlet and memorize flashcards containing terms like 1. nutritional intake 3. Nurses first action? Request PT referral Use this nursing care plan and management guide to help care for patients with obesity. Teach Study with Quizlet and memorize flashcards containing terms like A child 4 years of age has a mother who is employed and works from home. "I will wipe my nose gently if it is A nurse is planning care for a client who is having difficulty swallowing food at mealtime. The application of a patient-centred model underpinned by the concept of needs has several implications for practice. Apply the principles of infection control when caring for a patient with an eye infection. Study with Quizlet and memorize flashcards containing terms like The nurse is updating the plan of care for a pt who is 48 hr postop following a laryngectomy & is unable to speak. 1-23. The nurse documents in the plan to assess the client for which signs of acute graft rejection? 1. This guide equips you with the necessary information to provide effective and Access this comprehensive nursing care plan and management guide to deliver optimal care for clients facing challenges in performing self-care and activities of daily living. Instruct the client to take diphenoxylate/atropine 5 mg PO twice a day. The nurse is planning care for a client A nurse is planning care for a client who has major depressive disorder and is experiencing loss of appetite, insomnia, and the inability to provide self-care. Orienting the client to Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with the plan of care for a client who has a cerebral aneurysm . Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). The client has weakness on the right side of the body. Which of the following referrals should the nurse make for the caregiver? A. Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery. B Risk for injury related to denial of deficits and impulsiveness. The client is hesitant to have the device applied. Which of the following findings should the nurse expect?, A Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. The nurse suggests that the family might need respite care services. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? Mark the edges of stairs for contrast. 7° F (37. Loss of pereipheral vision. The nurse should recognize that this route a. Study with Quizlet and memorize flashcards containing terms like A home health nurse is interviewing the adult of a child of a client who has Alzheimer's disease. Which of the following interventions should be included in the plan of care?, A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. However, the most important consideration is the client's own coping skills. The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which interventions will the nurse add to the client's plan of care to assist with the with vision loss? Choose all that apply. Visual fatigue b. This guide equips you with the necessary Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Both eyes are assessed together, followed by the assessment of the right and then the left eye. Loss of central vision d. Which intervention in the plan of care to prevent injury at home? mark the edges of stairs for contrast. Which sign or symptom is associated with this eye Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Review prealbumin finding. Which of the following actions would the nurse include in the plan? SATA a. A nurse develops a plan of care for an older adult recently diagnosed with Lewy body dementia. The client's wound has healed by 0. Which of the following should the nurse include in the client's care plan? A. A nurse is planning care for a client coming into the emergency department via ambulance on a hot summer day with the following symptoms: temperature of 105°F (40. Many of us don't realize how much we rely on visual cues to accomplish all that we do in a single day. Halos when looking at lights RATIONALE A cataract is a cloudy or opaque area in the lens of the client's eye. Loss of peripheral vision c. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals facing obesity. With a focus on personalized care and addressing the specific needs of the elderly, geriatric nursing care plans help nurses to provide On assessment, the nurse finds that the client has blurred vision, loss of central vision, and distortion of vertical lines. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? Check the client's cheek on the affected side after meals to be sure no food 7. Which of the following manifestations should the nurse expect? a- a lucid period followed by an immediate loss of consciousness b- a change in the level of consciousness that develops over 48 hours c-neurologic deficits that increase up to 2 weeks post-injury d-cognitive perception that A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which nursing diagnosis should the nurse include in the plan of care? A Impaired physical mobility related to right-sided hemiplegia. Glaucoma is a chronic and serious disease that can result in permanent vision loss if not taken care of properly. Which of the following clients should the nurse assess first? A client who is postoperative with abdominal distention and no bowel sounds A client who has diabetes mellitus and a blood glucose level of 105 mg/dL A client A nurse is planning care for a client who has major depressive disorder and is experiencing loss of appetite, insomnia, and the inability to provide self-care. " Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following actions should the Study with Quizlet and memorize flashcards containing terms like A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following nursing interventions to promote development should be included in the plan of care? a. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. The nurse should expect which of the following findings?, A nurse instructs a female client about As our population continues to age, the demand for geriatric care continues to grow. , The nurse is caring for Mr. Reduces the risk of accidents caused by changes in visual fields/vision loss and papillary adjustment to ambient light. Medulla b. Which of the following interventions should the nurse include in the plan of care? (Select all that apply. Elevate Use this nursing care plan and management guide to help care for patients with HIV/AIDS. Once the nurse identifies nursing diagnoses for malnutrition, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. Risk for seizures related A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take?, A nurse is caring for a client who had severe traumatic brain injury 3 weeks ago, remain unconscious, and is unlikely to recover. 35 Study with Quizlet and memorize flashcards containing terms like A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. The patient may not be able to perform activities of daily living as normal if he/she cannot see properly. Position the client on their side to improve breathing. Administer diuretic 3. Although vision loss cannot be restored (even with treatment), further loss can be prevented. To prevent injury and encourage independence, the patient with vision loss should 1. The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. bladder control 2. Consult social services to arrange home meal delivery. Ensure the client wears their hearing aids is correct. Assess for pitting edema. The nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure ?, A nurse is planning care for several clients and is considering the clients ' The nurse identifies the nursing diagnosis of deficient knowledge related to a new hearing aid for a client. Which nursing intervention will provide tactile simulation? a. She earned her BSN at Western Governors University. Vision loss—even mild vision loss—can be devastating and life-changing. Monitor client’s cardinal fields of vision. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a body mass index (BMI) of 18. What assessment finding is characteristic of otitis externa? A) Tophi on the pinna and ear lobe B) Dark yellow cerumen in the external auditory canal Study with Quizlet and memorize flashcards containing terms like A nurse is collecting data from a client who has a leaking cerebral aneurysm. performing keratoplasty B. NURSE. Allow the client to verbalize feelings. Leg cramps C. Fever, A nurse is planning care for a client following a Study with Quizlet and memorize flashcards containing terms like A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. Keep suction equipment at the bedside. Nursing Care Plans and Management. Which functional consequence would be most important to monitor in this older adult? A) Development of visual hallucinations B) A visual acuity score of 20/30 C) Improved 3. 3. Client's plan of care should include:, a nurse is assisting a client who has generalized weakness out of bed to wheelchair. Nursing2019: November 2015 - Volume 45 - Issue 11 - p 55-58 doi: 10. Skin breakdown E. , 3. (1) Describe the room and its contents in detail, so that the patient can form a mental image of his room. 0000471416. Which of the following actions is the nurse's priority for the client? Keep the client's environment free from clutter. What will the nurse include in the presentation? Select all that apply. Which of the following Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has a head injury following a motor-vehicle crash. Left hemisphere d. Marcelle Freire Caring for a patient with vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client Explanation: To assist a client with vision loss during feedings, the following interventions might be included in the plan of care: Assigning a staff member to feed the What is the nurse's most appropriate action? A. The client's eye examination report shows an intraocular pressure of 24 mm Hg. Change the battery after 80 hours of use B. ), A nurse is assisting in the planning of preventative care The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. The nurse can expect which major problem early in the recovery period? 1. The client is aphasic. Cataracts in adults usually develop with advancing age and can be hereditary. touch the client gently to announce presence d. Nursing Diagnosis: To monitor worsening of vision loss and treat accordingly. Monitor client's cardinal fields of vision. Falls C. B) Determine apical pulse prior to administering. See Table 7. Administer warfarin c. Warnecke P. In the following section, you will find nursing care plan examples for malnutrition. " B. Which client Study with Quizlet and memorize flashcards containing terms like The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following statements is appropriate "Without treatment glaucoma can cause blindness" A nurse is planning care for a client one day postoperative following a detached retina repair. Which of the following interventions should the nurse include in the plan of care? A) Weigh the client weekly. Planning, Individualizing, and Documenting Client Care Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. monitoring the client's blood glucose levels A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. 6° C) 2. Losing one's vision can be frightening, and losing the ability to care for yourself is something none of us want to ever think about. Which of the following interventions should the nurse included in the plan of care? A. Restlessness b. The nurse should place the client in which of the following BMI categories?, A nurse is assessing a client who has an inadequate dietary intake of vitamin C. Providing a back rub with morning and evening care. The nurse is planning care for a client with right-sided weakness and aphasia from a transient ischemic attack (TIA). Remind the client of the importance of deep breathing and coughing exercises. performing phacoemulsification C. Use a sign language interpreter is When planning care for a client with vision loss, the nurse should include interventions to assist the client with feeding. Nurses do this activity every shift. Includes our easy-to-follow guide on how to create nursing care plans from scratch. Monitor for contractures. Bright flashes of light and floaters d. The client is sleepy but arousable. The nurse anticipates that the client has which condition? Heat exhaustion Blunted febrile response Hyperthermia Blurred vision Hyperactive bowel sounds Urinary incontinence Moist skin. Keep the client lying in a supine position. Use aseptic technique when performing an eye examination or instilling drugs into the eye. SENSORY DEPRIVATION: A, E, F SENSORY OVERLOAD: B, C, D When taking actions, the nurse should encourage visitors, increase the ringer volume on the client's phone, and communicate frequently with the client who has sensory deprivation to provide meaningful stimulation for the client. Physical therapy C. Includes detailed overlooked in the home care setting when treating patients for other conditions. Which of the following interventions should the nurse include in the plan? a. "Respite care allows the primary caregiver time away from day-to-day care With both conditions, it is crucial to get the correct diagnosis so the appropriate management strategy can be implemented. Which of the following strategies should the nurse include in the plan? Choose Macular Degeneration Nursing Care Plan 1. Physical Orientation. The nursing assessment shows a respiratory rate of 10 with deep tendon reflexes of 0. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals facing HIV/AIDS. In a long-term care or home setting, observe the client’s ability to perform ADLs. Medication administration record D. "I will sleep on my left side after surgery. decreases the client's risk for reactions, A nurse is planning care for a client who Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client with visual impairment. ) a. (Source: a caregiver’s eye on elders with low vision (abstract). The nurse should stress the importance of complying with the prescribed treatment program Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has. A nurse is initiating discharge planning for a client who has a stroke and is experiencing R side weakness. Which area of the brain should the nurse realize was affected in this client? a. Which finding would indicate that bleeding has occurred because of retinal detachment?- A nurse is assisting with planning care for a client who is having difficulty swallowing food at mealtime. The nurse is assigned to care for a client with a A client has had vision loss because of glaucoma. Measure the client's abdominal girth e. Keep objects in the client’s room in the same place. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) a. Identification wristband, A nurse is planning care for a client who has pernicious anemia. Administer Change-of-Shift Report Nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. is the safest option c. A nurse is reinforcing teaching for a client who has glaucoma. Many clients report vision difficulties, including poor visual memory, a decrease in balance, decreased depth perception, and Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has acute renal failure. Option 3: Thicken liquids on the client's tray. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? Alcohol Caffeine Cocaine Inhalants, A nurse is A nurse is planning care for an older adult client who is receiving treatment for malnutrition. Which of the following nursing diagnoses should receive further validation? 1. Complete vision loss-The nurse should expect a client who has a Study with Quizlet and memorize flashcards containing terms like A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. Client also reports nausea, vomiting, and dyspepsia. The plan of care includes assessment of specific gravity every 4 hours. channel d. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Instruct the client on daily muscle stretching. A, B, D, E Rationale: When planning care for a client diagnosed with MS, the nurse needs to address the following problems: impaired physical mobility, risk of fatigue, altered urinary elimination patterns, and risk of hopelessness. a nurse is planning care for a client who has a new prescription of methotrexate. C) Provide total assistance with all ADLs. Which of the following interventions should the nurse include in the plan of care to assist the client with 1-23. The nurse identifies the diagnosis: Anticipatory Grieving related to loss of vision. He as gradually lost much of the ability to hear in both A. When planning care for this client, which assumptions by the nurse are appropriate based on the provided data? Select all that To prevent vision loss. A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. A home health nurse is planning care for an older adult client who has impaired vision. Which activities would be appropriate components of the care plan for this client? Select all that apply. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care to improve self-feeding for a client who has vision loss. Nursing Diagnosis Guide and List: All You a nurse is planning care for a client who has vision loss. Assess causative and contributing factors. Cover the client with an electric blanket if extremities become mottled. Large print materials are used for clients who have vision loss. Administer IV fluids evenly over 24 hr. The nurse should assess how the client feels about this decision and what its impact will be. ) Also called low vision, it is defined as loss of eyesight that cannot be corrected with glasses, medicine, or surgery. If nurses are to meet the challenges of managing patients with visual impairment, they A. A nurse is planning care for an older adult client who is receiving treatment for malnutrition. Encourage weightlifting Select all that apply. Which of the following information should the nurse plan to include?, A nurse in a provider's office is C. The nurse Study with Quizlet and memorize flashcards containing terms like The nurse teaches the caregivers to care for the clients' hearing aids. Ensure there is high-wattage lighting in the client’s room. Presbyopia, the gradual loss of the ability to focus on In Brief. At meal time, after placing the food tray in front of the client, what is the next most appropriate action by the nurse ? a. D) Instruct the patient on daily muscle stretching. When a family member asks how respite care can help, which of the following responses should the nurse provide? A. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Desired Outcome: The patient will be able to prevent trauma or injury by means doing activities that can be done within the parameters of visual limitation and by modifying environment to adapt to current vision A hospice nurse is planning end-of-life comfort care for a client. Geriatric nursing care plans are an essential component in ensuring the comfort and well-being of our elderly population. Mark Luckowski, a psychiatric Macular Degeneration Nursing Care Plan 1. Approach the client from the side. Orient Dr. To prevent injury and encourage independence, the patient with vision loss should receive a thorough orientation to his surroundings. Which of the following interventions should the nurse include in the plan of care? Place the client in semi-Fowler's position. allow extra time for the client to perform tasks b. Tilt the client's head backwards when he swallows. Instruct the client to actively Nursing Diagnosis: Disturbed Sensory Perception (Auditory) related to damage in the inner ear secondary to Meniere’s disease as evidenced by recurrent vertigo, tinnitus or ringing in the ears, verbal complaint of hearing and communication problems Desired Outcome: The patient will be able to cope with the auditory loss as evidenced A nurse is contributing to the plan of care for a client who has labyrinthitis. Last updated on May 17th, 2022 at 05:41 pm. Which of the following actions should the nurse include in the plan of care? A. Administer IV fluids to the client evenly over 24 hr b. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. 4. The client has What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client? A 6 cm x 4 cm wound with malodorous, yellow exudate The client's wound will heal by 1 cm by the end of 5 days. ) A. Encourage a Study with Quizlet and memorize flashcards containing terms like A highly agitated client paces the unit and states, "I could buy and sell this place. Risk for falls related to muscle weakness and sensory loss. quadriceps setting 4. Apply an eye patch to the right eye. This helps to prioritise the client's needs and assists in setting person-centred goals. After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. 5 cm on day 3 of wound care. Diabetic Retinopathy Nursing Care Plans Diagnosis and Interventions. b) Allow the client to rest for 15 min before meals. Which area of the brain should the nurse realize was The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. These interventions may include: Providing verbal cues and descriptions of the food on the plate Change-of-Shift Report Nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. Which of the following are expected findings? (select all that apply) A. place the eating utensils in the client's hands b. Stand or sit in the client's line of vision. Which intervention will be part of the plan? a) Assess vision to determine functional capability b) Explain botulinum injection procedure and risks c) Assess the child's ability to convey information d) Teach parents to make vinegar and alcohol eardrops Study with Quizlet and memorize flashcards containing terms like 1. Cluster the Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has cystitis. Which symptom should the nurse expect because of this health problem? a. With assistance from the caregiver, the client will be able to interrupt non-reality-based thinking. total disorientation. People with vision problems can get depression and have an increased risk of falls and hip fractures. Remove the battery before turning the hearing aid off D. Communicating with patients A nurse is planning to use the nursing process to care for a client who is experiencing grief. Other recommended site resources for this nursing care plan: Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. The client has a new diagnosis of diabetes and his partner is at the bedside. A patient diagnosed with cataracts asks how they The nurse is caring for an older adult client that recently lost total vision in both eyes due to macular degeneration. and a PACU RN at Chester County Hospital, West Chester, Pa. Administer bronchodilators as ordered. B) Order a low-residue diet. The nurse should recognize this as a manifestation of which of the following diseases? The nurse is assisting in developing a teaching plan for the client with glaucoma. d. What is the nurse's priority action? 1. Seizures D. 2. Which of the following identifies the accurate procedure for this visual acuity test? A. Stop magnesium and prepare to give . Elevate the head of the bed 30 degrees. This is. Patients with glaucoma may experience vision loss, particularly in the peripheral areas, and have difficulty seeing in low-light conditions. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process. Which of the following interventions should the nurse include in the plan of care to assist the client with A nurse is planning care for a client who has vision loss. Which of the following actions should the nurse take first? Establish whether the client's grieving is healthy or complicated Reasoning: When using the nursing process, the first action the nurse should take is to establish whether the client's Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury who has paraplegia. Amy Luckowski is a nursing faculty member at Widener University in Chester, Pa. Which of the following actions should the nurse take? (Select all that apply) A. 5°C), absence of sweating, and loss of consciousness. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. C Impaired 27. The client is visually impaired. Which statement is most Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who demonstrates manipulative behavior. D. Hypotension d. Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. Exercise the right eye twice a day. Allow the client to rest for 15 min before meals. The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). the client begins to have seizure activity including loss of Risk factors for sensory deprivation include experiencing total vision or hearing loss. Formats include face to face, audiotaping, or presentation during walking rounds in each client's room (unless the client has a roommate or visitors are present). Nursing care planning goals for patients with diabetes include effective treatment to normalize blood glucose levels and decrease complications using insulin replacement, a balanced diet, and exercise. This chapter will explain how to use the nursing ANS: B Loss of driving is often associated with loss of independence, as is decreasing vision. Study with Quizlet and memorize flashcards containing terms like When a person selects, organizes, and interprets sensory stimuli, the process is termed:, The nurse is teaching a group of clients about general eye care to prevent vision loss and eye injury. use of aids for ambulation, The primary reason the nurse encourages a client A nurse is developing a plan of care for a school age child who underwent a surgical procedure that resulted in a temporary loss of vision. Study with Quizlet and memorize flashcards containing terms like The nurse should assess an older client with macular degeneration for; -loss of central vision -loss of peripheral vision -total blindness -blurring vision, The nurse is communicating with a primary care provider about medical interventions prescribed for a client. Blurred vision, When caring for a client Study with Quizlet and memorize flashcards containing terms like 1. Which of the following should the nurse include in the teaching?, A nurse is preparing to administer ofloxacin otic drops to an adult pt who has otitis externa. Place prone for 30 minutes, 4 times per day. Occipital lobe c. To reduce the morbidity of the disorder, the condition is best managed by an interprofessional team that is dedicated to the management of patients with vision problems. a. (Care, 2003 an;22(1):12 5. A nurse is planning care for a client who has AIDS and has developed stomatitis. 42130. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving medication intramuscularly. 3b for basic nursing interventions to implement for a variety of sensory alterations. Raise head of bed (HOB) to 45 degrees 5. Fever, hypotension, and polyuria 2. What should the nurse include when assisting in the teaching about this health problem?, 2. Have the client sit alone in a quiet atmosphere during meals. psychic blindness. Fatigue, A client with MS is receiving Baclofen. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. pdf from OT 564 at University of Southern California. Rationale: Although early intervention can prevent blindness, patient faces the possibility or may have already experienced partial or complete loss of vision. A nurse is planning care for a client who had Study with Quizlet and memorize flashcards containing terms like The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. Dysuria D. Learn about the nursing diagnosis for otitis media and how it can be used to develop effective A nurse is planning care for a client who has depression. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is recovering from a stroke and has right- sided homonymous hemianopsia. Which of the following instruction should the nurse Study with Quizlet and memorize flashcards containing terms like When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:, Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?, A nurse is obtaining a history from a new client with glaucoma. Monitor for orthopnea 4. Remove the battery when the hearing aid is not being worn, The nurse plans care for a client who has had gradual vision loss. Loss of visual acuity c. Which of the following intervention should be included in the plan of care? Study with Quizlet and memorize flashcards containing terms like When assessing a client with multiple sclerosis for potential complications of the disease the nurse should assess the client for which symptoms? Select all that apply. 1. Which of the following interventions is the nurses priority?, a nurse is caring for a client who has a spastic bladder following a spinal cord injury. Option 2: Provide small-handle utensils for the client. ACTIVE LEARNING TEMPLATE: Basic Concept Jacqueline Hayes STUDENT Cultural and Spiritual Nursing Care: Communicating With a Client Who Speaks a Different Language Than the Nurse About. sender c. the nurse should plan to monitor the Study with Quizlet and memorize flashcards containing terms like A nurse is reinforcing discharge teaching with a pt following cataract extraction. Dizziness c. Which of the following actions are appropriate to include in the plan of care? (Select all that apply. The charge nurse should ask a staff member to first see the client in the 1. Regular eye appointments and compliance with medication are vital to helping slow The nurse plans care for a client who has had gradual vision loss. Provide therapeutic massage for pain relief. Provide the client with a salt substitute. Diabetic Retinopathy A nurse is planning care for a client who has vision loss which of the following interventions should the nurse include in the plan of care to assist the client with feeding. second stage of labor who has Study with Quizlet and memorize flashcards containing terms like The client is to have pneumatic compression devices applied. Jaw pain Drowsiness Blurred vision Tinnitus Muscle pain, A health care professional is caring for a patient who is to begin taking calcitonin-salmon (Miacalcin) intranasal spray to treat osteoporosis. These interventions aim to improve the patient’s ability to manage anxiety and enhance their A nurse is planning to discharge a client who has quadriplegia to his home. the client begins to have seizure activity including loss of A nurse is planning care for a client who has vision loss. Chart B. Impaired mobility related to spasticity and fatigue. Nursing Diagnosis: Because the nurse, who is a stranger, may constitute a threat to the very nervous client, therapeutic skills must be aimed toward putting the patient at ease. Report to the health care provider new changes in vision. One Study with Quizlet and memorize flashcards containing terms like Which action would be considered in the collaborative plan of care for a client w/ increased lens density? SELECT ALL THAT APPLY A. A client has learned to sleep through the frequent beeping of the intravenous pump. Position the newborn to promote extension of muscles. Which of the following should the nurse include in the care plan? A. Study with Quizlet and memorize flashcards containing terms like fluid accumulation in the pericardial sac; manifestations include hypotension, jugular vein distention, muffled heart sounds, and paradoxical pulse (variance of 10 mmHg or more in systolic blood pressure between expiration and inspiration), A nurse is orienting a newly licensed nurse on the Discharge Planning. which of the following interventions should the nurse include in the plan of care to assist the cl Study with Quizlet and memorise flashcards containing terms like A preeclampsia client is being treated with magnesium sulfate. Photophobia - The nurse should expect photophobia in a client who has a migraine headache. The family voices concern about rehabilitation after discharge. Use fingertips when calming the newborn. Encourage the client to void every hour. Implement a low-sodium diet d. Examine trends in weight loss. Aphasia E. Which of the following actions should the nurse plan to take? A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. Which of the following statements by Use the Snellen chart to assess distant vision. Which of the following instructions A home health nurse is planning care for an older client who has impaired vision. Place needed items on the right side. 1097/01. Delivering meticulous oral care. compensation. Which of the following strategies should the nurse include in the plan? The nurse is assigned to care for a client with a diagnosis of detached retina. Which of the following instruction should the nurse include?, A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Encourage ambulation. Nurse Kaye is carrying out her operative teachings for an older client who will have cataract surgery on the right eye. A nurse is caring for a client who has an epidural hematoma. Which of the following actions should the nurse include in the plan of care? (Select all that apply. The nurse knows that the caregiver needs further teaching when the nurse notes the caregiver: A) Changing the battery after 82 hours of use B) Purchasing several new batteries when a few remain C) Removing the battery Nursing Care Plan for Cataracts 2. The nurse concludes that the client needs further understanding about the teachings if he says: A. Place client in Trendelenburg position and apply oxygen. Select all that may apply. Study with Quizlet and memorize flashcards containing terms like A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in: A. decoder, A nurse is planning a Study with Quizlet and memorize flashcards containing terms like Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? a. Close the door to the client's room. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in A client has a partial loss of peripheral vision. The nurse is planning care for a client in the acute recovery phase after an ischemic stroke. Which of the following clients may have a false positive result?, A nurse caring for a client who has Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has a terminal cancer and has a prescription for morphine. This valuable resource provides a wealth of information on nursing assessments, interventions, goals, and nursing diagnoses specifically designed to Study with Quizlet and memorize flashcards containing terms like A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P. Impulse control difficulty B. Dehydration B. Limit fluid intake with meals C. depression. Floating filaments in vision, 2. A. approach the client from the side c. The nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA). Study with Quizlet and memorize flashcards containing terms like The nurse is developing a teaching plan for a client with glaucoma. Which of the following should the nurse include in the patient's care plan? A) Encourage patient to void every hour. Which of the following interventions should the nurse include in the plan of care to assist the client with feedings? Option 1: Assign a staff member to feed the client. A client believes their hearing has become more acute since the loss of his vision. Subsequent diagnostic testing has resulted in a diagnosis of an intra-axial brain tumor. As always, refer to an evidence-based nursing care planning resource when customizing interventions for specific patients. " The client's mood fluctuates from fits of laughter to outbursts of anger. Orient the The charge nurse has received a change-of-shift report on the following clients in labor. The ophthalmic nurse should assess Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has cirrhosis of the liver. Assign an assistive personnel to feed the child. Nursing Care Plans. The nurse is planning care a. C) Administer the medication 30 min prior Provide the client with large print materials is incorrect. A nurse is providing care for a client who has a sensory deficit. Which actions should the nurse plan to take first, A nurse is teaching a pt who has a new RX for TPN through a central line. Background: People with low vision or blindness may experience anxiety, fear, and depression—sometimes severe—as a result of the challenges encountered when Glaucoma is a chronic and serious disease that can result in permanent vision loss if not taken care of properly. Which of the following assessments provides the most accurate measure of client's fluid status?, A nurse is teaching a client who has lower extremity weakness how to use a 4-point crutch gait. [2] Loss of central vision with symptoms such as blurred central vision, distorted vision that causes difficulty driving Study with Quizlet and memorize flashcards containing terms like What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? Select all that apply 1. In planning care, the nurse documents ways to minimize the obstacles to successful communication with this client. Turn the client every 2 hours. Ensure the room is brightly lit. Based upon this information, what nursing diagnosis would be applicable to this family, A hospital client has been Nursing Care Plan for Glaucoma 1. The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. Client rates pain as 7 on a scale of 0 to 10. ensure there is a high-wattage lighting in the clients room d. When providing assistance with feeding a client who has visual loss, the nurse has to use a number of different strategies. Explanation: When planning care for a client with vision loss to assist with feeding, the nurse should consider several interventions. Study with Quizlet and memorize flashcards containing terms like When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? A Recognizing that eye damage caused by glaucoma can be reversed in the early stages B Giving The nurse should use which of the following is a priority source of verification? A. Encourage the patient to promote sufficient lighting at home. has the slowest absorption rate d. First and foremost, the nurse has to make sure that the patient is aware of the layout of the kitchen, dining room, and any other locations in the facility where food may be provided. Which choice will best meet the client's nutritional needs at this time A) Offer a green salad topped with chicken pieces. Which interventions does the nurse include in the client's plan of care? (Select all that apply. Considering this a nurse is planning care for a client who has vision loss. A nurse is contributing to the plan of care for a client who has labyrinthitis. first stage of labor whose contractions are occurring every 30 seconds 3. An effective report should: Include significant Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Limit fluid intake. position A weight loss will alert the nurse to possible fluid imbalance early in the process. During the acute phase of CVA, efforts should focus on survival needs and prevent further complications. The client has expressed thoughts of suicide. A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. Provide oral hygiene with a firm-bristled toothbrush after each meal D. See an expert-written answer! Cornea. Which of the following should the nurse include in the care plan? A) Brightly colored throw rugs to lighten up 1. Which of the following interventions should the nurse include in the plan of care? a) Place the client in semi-Fowler's position. increases infection rates b. While bathing the client, the AP Study with Quizlet and memorize flashcards containing terms like A nurse has just received change-of-shift report on four clients. When identifying client goals, which of the following goals is the highest priority, Nurse caring for client who has depression. Provide frequent feedings during the day. The right eye Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has experienced a right-hemispheric stroke. Attorney B. Which of the following actions should the nurse take? (SATA) kindly explain your answer a. Which instruction should the nurse include in the plan of care?, The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Order a low-residue diet. Which of the following is the The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Assess the client for pitting edema d. Talk loudly and slowly to the The authors have disclosed that they have no financial relationships related to this article. A client reports "the worst headache" of her life with associated blurred vision. It makes everyday tasks such The nurse is caring for a client on the rehabilitation unit who has hearing loss. After teaching a client about caring for his new hearing aid, the nurse determines that the outcome has been achieved when the client states which of the following? 1- "I need to wipe the ear mold daily with a moist washcloth. Nursing Interventions. The nursing interventions for a dementia Study with Quizlet and memorize flashcards containing terms like A nurse is caring for client newly diagnosed with diabetes mellitus type 2 who has a blood glucose level of 48 mg/dL. Which is the most accurate documentation of this client's behavior?, A client diagnosed with bipolar I disorder is distraught over insomnia The nurse is planning care for a client in the acute recovery phase after an ischemic stroke. Nurses play an important role in caring for patients with anxiety by developing individualized nursing care plans that include symptom assessment, emotional support, relaxation techniques, coping education, and promoting overall well-being. Explain sounds the child is hearing. Monitor Central venous pressure (CVP) 2. The results of this test will allow the nurse to assess what Planning care is essential in the delivery of appropriate nursing care. A TIA is a forewarning that the patient is at risk for a cerebrovascular accident (stroke). Nursing Care Planning and Goals. Use this nursing care plan and management guide to help care for patients with amputation of the limbs. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? a. Which clinical manifestations would the nurse document? and diplopia (double vision) are visual field deficits that a client with a CVA may experience, but they are not motor losses. The major nursing care planning goals for dementia are: The client will accept explanations of inaccurate interpretations within the environment. Rinse the mouth with chlorhexidine solution every 2 hr B. NURSING CARE OF THE PATIENT WITH VISION LOSS. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals facing amputation. Planned care will change as a Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has hypertension and is to start taking metoprolol. Allow extra time for the client to perform tasks. Study with Quizlet and memorize flashcards containing terms like Which safety intervention would the nurse include in a plan of care for a client with somatic disorder who reports loss of vision? Select all that apply A) Apply restraints B) Administer sedatives C) Put the call light within reach D) Orient the client to surroundings E) Use Study with Quizlet and memorize flashcards containing terms like Home safety: Planning care for a client who has vision loss, Cystic Fibrosis: Priority Assessment for a Group of children, Infection Control: Infectious Diseases to and more. , Client has been places in wrist restraints, nursing actions: and more. The nurse is planning care for a client Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has experienced excessive fluid loss. The nurse should provide a private room, limit Chapter 49 Care of Patients with Eye and Vision Problems M. Which condition would the nurse suspect is causing these findings? 1) Reduced elasticity of the lens 2) Unevenness in the cornea 3) Excess production of aqueous humor 4) Nontransparent substances in the vitreous humor Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the care plan of a client with Multiple Sclerosis. Many eye conditions cause varying degrees of visual impairment. Whic info should the nurse include in the teaching, A Study with Quizlet and memorize flashcards containing terms like The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). c. Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a community education course about the physical complications related to substance use disorder. A client with vision loss has begun buying large-print books. Provide total assistance with all ADLs. What is the best response by the nurse? A. Which action should the nurse take?, A nurse in a provider's office performs a fecal occult blood test with a positive result on a client. However, routine eye care is not among these services. " 2- "I need to Study with Quizlet and memorize flashcards containing terms like A nurse contributing to the plan of care for a client who has severe depression following loss of spouse. Nurses should encourage clients who have a hearing loss to wear their hearing aids and assist them with cleaning the hearing aids. Purchase several new batteries when a few remain C. first stage of labor who has an oral temperature of 99. daily. Left hemiplegia C. Use 40-watt bulbs in lighting fixtures. Cantrell, a 69-year-old client. Enhance your understanding of nursing assessment, interventions, goals, and nursing Use the Snellen chart to assess distant vision. Which of the following interventions should the nurse plan to implement? A. Flashes of bright light The nurse should expect a client who has a retinal detachment to see flashes of bright light or floating dark spots in the affected eye as the retinal layers separate. Which of the following interventions should the nurse include in the plan of care? A. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights, A nurse is planning care for a client diagnosed with Otitis media is a common ear infection that can cause pain, fever, and hearing loss. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions should the nurse include in the plan of care? A nurse is planning care for a client who has vision loss. Provide the client with a salt substitute c. B) Offer a bowl of vegetable soup. A client with hearing loss has learned to communicate using sign language. The client with halo traction cannot drive because the traction limits mobility and impairs range of vision. Tachycardia B. Which characteristics are associated with this condition? Select all that apply. Effective nursing care plans should include comprehensive nursing management and interventions for otitis media to ensure optimal patient outcomes. A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA). Order sheet C. When the nurse encourages the client to join an activity Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. This guide equips you with the necessary information to provide Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge instructions to a client during a follow-up telephone call. Encourage the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client with a fecal impaction. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a preterm newborn. Nursing Diagnosis: Risk for Trauma/Injury related to loss of vision and/or reduced visual acuity. turn the plate so that the food is facing away from the client c. Presbyopia, the gradual loss of the ability to focus on nearby objects, may begin around age 40. Identify patients who can benefit from vision rehabilitation. Client is awake, Study with Quizlet and memorize flashcards containing terms like The nurse is planning care for a client who has a right hemispheric stroke. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in Tips for caring for someone with vision loss. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following actions should the nurse take?, A nurse is collecting data from a client Study with Quizlet and memorize flashcards containing terms like The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which finding should the nurse recognize as an adverse reaction to the drug? A. Which action should the nurse perform first?, A nurse is assessing a newly admitted client diagnosed with diabetes mellitus type 2. "This device will help push blood from the small vessels to the large vessels in your legs and prevent you from developing a blood clot. Vision loss is a growing challenge for older Americans. The nurse is collecting data from a patient with cataracts. Linda Workman Learning Outcomes Safe and Effective Care Environment 1. The home care nurse is instructing a nursing assistant about interventions to aid patients with vision impairment. veinc rxq clevy pqrh zhvkkp xtblpb pahz wij syk etpjur