A nurse is planning care for a client who has vision loss. Put the call light within reach. Which action should the nurse perform first?, A nurse is assessing a newly admitted client diagnosed with diabetes mellitus type 2. 1. Provide total assistance with all ADLs. the client becomes agitated and combative when the nurse approaches him. To prevent injury and encourage independence, the patient with vision loss should receive a thorough orientation to his surroundings. A nurse is caring for a client who had a stroke and has aphasia. NURSING CARE OF THE PATIENT WITH VISION LOSS. Apr 30, 2024 · Use this nursing care plan and management guide to provide care for patients with macular degeneration. Study with Quizlet and memorize flashcards containing terms like A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights, A nurse is planning care for a client diagnosed with bipolar The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. The nurse suspects what? A nurse is planning care for a client who has experienced excessive fluid loss. d. Macular degeneration 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. Hypotension 2. Encourage the client to rise slowly when A nurse is caring for an older adult client who reports unintended weight loss. 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. c. The client is hesitant to have the device applied. Use 40-watt bulbs in lighting fixtures. Which of the following Apr 30, 2024 · This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Allow the client to rest for 15 min before meals. Desired Outcome: The patient will retain optimal vision while preventing permanent loss The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which characteristics are associated with this condition? Select all that apply. (C) Provide the client with an alphabet board. Study with Quizlet and memorize flashcards containing terms like The client is to have pneumatic compression devices applied. Client with intraocular pressure reading of 24 mm Hg b. (Care, 2003 an;22(1):12 5. 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 decreases over several months post-injury A hospice nurse is planning end-of-life comfort care for a client. D. Apply restraints. The nurse should monitor the client for which of the following complications? (Select all that apply. 1-23. Glaucoma B. Client rates pain as 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?, a nurse is caring Apr 30, 2024 · This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Which of the following interventions should the nurse include in the plan of care? A. Provide the client with a salt substitute c. The nurse should remind the client that this herbal supplement has which of the following actions?, A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Polyuria 3. Aug 9, 2024 · This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. 2. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) a. Encourage ambulation. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has. ) 1. A nurse is assisting with planning care for a client who is having difficulty swallowing food at mealtime. Nursing Diagnosis: Disturbed Sensory Perception (Visual) related to the deterioration of macula as evidenced by verbal complaint of vision problems such as blurry or patchy vision, floaters, eye pain and redness. 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 . What interventions will the nurse prioritize when planning care? Select all that apply. Client also reports nausea, vomiting, and dyspepsia. b. Talk loudly and slowly to the Oct 4, 2021 · Nursing Care Plan for Diabetic Retinopathy 1. , Downingtown, Pa. B) Introduce herself in a firm, loud voice at the doorway of the room. Which client should the nurse see first? a. 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 A. A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. , is totally blind. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. Client is awake, alert, and oriented x3. Which of the following should the nurse include in the care plan? A) Brightly colored throw rugs to lighten up the client's room. Turn the client every 2 hours. Provide the client with a structured schedule of daily activities. Which of the following interventions should the nurse include in the plan? a. Jun 20, 2024 · A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. 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 actions is the nurses priority?, A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck's traction. B) Fluorescent overhead lights on at night. Aug 6, 2024 · 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 therapeutic communication, Which action would the nurse 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). The nurse is planning care for a client in the acute recovery phase after an ischemic stroke. Lung sounds a nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. 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). The nurse should identify that these manifestations indicate which of the following eye disorders? A. provide small handled utensils for the client . Option 2: Provide small-handle utensils for the client. , The nurse is caring for Mr. Administer IV fluids evenly over 24 hr. Maintain a Study with Quizlet and memorize flashcards containing terms like The registered nurse taking shift report learns that an assigned patient is blind. D) State The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Caring for a patient with vision loss. 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. Which of the following pieces of information is the priority for the nurse to provide?, A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Select all that may apply. Warnecke P. The nurse plans care for a client who has had gradual vision loss. 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 is the nurses priority?, A nurse is caring for a client who has a retinal detachment. Assess the client for pitting edema d. However, the most important consideration is the client's own coping skills. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. 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). "Because you are in bed it is 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. Which of the following actions should the nurse take?, A nurse is evaluating 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. Which of the following should the nurse include in the client's care plan? A. Which of the following interventions should the nurse include in the plan of care to assist the client with feedings? A) assign a staff member to feed the client B) Provide small-handle utensils for the client. 5 cm on day 3 of wound care. Option 3: Thicken liquids on the client's tray. c) Tilt the client's head backwards when he swallows. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). The nurse should inform the client that ability to taste which of the following can decrease with age? (Select all that apply. Physical Orientation. Instruct the client on daily muscle stretching. A nurse develops a plan of care for an older adult recently diagnosed with Lewy body dementia. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. 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 liquids on the client's tray Use a clock 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. 3. Feeding is an intimate activity, and usually, it should be encouraged for the patient to do it independently if possible. What contributing factors should the nurse include in the teaching?, 2. Stand or sit in the client's line of vision. Which finding indicates the client's blood A client has a partial loss of peripheral vision. 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 visual acuity after medications for dementia D) Growth of daily weight--> daily weight provides important information about client's fluid status. Assess for pitting edema. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. Absence of bowel sounds 5. Mark Luckowski, a psychiatric rehabilitation primary coach at Human Services, Inc. Which of the following parameters should the . A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Cantrell, a 69-year-old client. Which of the following actions should the nurse plan to take first? (A) Determine the client's reading skills. Cover exposed extension cords with throw rugs. It makes everyday tasks such Sep 25, 2023 · When planning care for a client who has vision loss, enhancing independent functioning is crucial, so the nurse would consider interventions that facilitate this. An effective report should: Include significant objective information about the client's health A. The client has complete bilateral paralysis of the A nurse is seeing clients in the ophthalmology clinic. Client with a tearing, reddened eye with exudate 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. 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 The home care nurse is preparing to visit a client who has undergone renal transplantation. One, some, or all responses may be correct. Change-of-Shift Report Nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. Position the client on their side to improve breathing. (Source: a caregiver’s eye on elders with low vision (abstract). A home health nurse is planning care for an older client who has impaired vision. 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. The client's eye examination report shows an intraocular pressure of 24 mm Hg. 4. Encourage the client to void every hour. Ensure the room is brightly lit. depression. A nurse is contributing to the plan of care for a newly admitted client who has obsessive-compulsive disorder (OCD). -Deep vein prophylaxis-Falls prevention-Swallowing precautions-Reorientation exercises-Stroke prevention education A nurse is contributing to the plan of care for a client who has labyrinthitis. Study with Quizlet and memorize flashcards containing terms like A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Remove the battery before turning the hearing aid off D. and a PACU RN at Chester County Hospital, West Chester, Pa. I've had these funny feelings in my stomach. Which of the following actions should the nurse take to promote communication? (Select all that Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a preterm newborn. Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. Cover the client with an electric blanket if extremities become mottled. Order a low-residue diet. Dec 4, 2023 · A nurse is planning care for a client who has vision loss. The client has weakness on the right side of the body. 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 educating through writing for other healthcare professionals and the A nurse is planning care for a client who is having difficulty swallowing food at mealtime. Keep the newborn in a well 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. The client's wound has healed by 0. Provide frequent feedings during the day. I'm scared that I might have cancer. Retinal detachment C. What is the best response by the nurse? A. The nurse documents in the plan to assess the client for which signs of acute graft rejection? 1. Study with Quizlet and memorize flashcards containing terms like 1. He as gradually lost much of the ability to hear in both ears due to working with loud overlooked in the home care setting when treating patients for other conditions. ) Also called low vision, it is defined as loss of eyesight that cannot be corrected with glasses, medicine, or surgery. Change the battery after 80 hours of use B. A gain or loss of 1 kg (2. Hypoglycemia 4. A nurse is teaching a newly licensed nurse about contributing factors for sensory alterations. The client is aphasic. C. " B. Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. a. b) Allow the client to rest for 15 min before meals. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Administer sedatives. The client reports that their food does not taste right. Use fingertips when calming the newborn. Provide the client with a salt substitute. Administer IV fluids to the client evenly over 24 hr b. 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 ' risk for stroke . 5. 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. Fever, hypotension, and polyuria 2. Purchase several new batteries when a few remain C. Orient the client to surroundings. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. Which of the following strategies should the nurse include in the plan? Use of auditory or tactile materials Rationale: the use of auditory or tactical materials bypasses the need to see or read. total disorientation. Have the client sit alone in a quiet atmosphere during meals. Client whose red reflex is absent on ophthalmologic examination d. psychic blindness. Which of the following interventions should the nurse include in the plan of care? Place the client in semi-Fowler's position. Client who has had cataract surgery and has worsening vision c. Apply the principles of infection control when caring for a patient with an eye infection. Cluster the newborn's care activities. Limit fluid intake. ) Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Remove the battery when the hearing aid is not being worn, The nurse plans care for a client who has had gradual vision loss. 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. (1) Describe the room and its contents in detail, so that the patient can form a mental image of his room. Which of the following strategies should the nurse include in the plan? Use of auditory and tactile materials. Which of the following interventions should the nurse include? Use detailed explanations when providing instructions to the client. 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. C) Lightly touch the patient's arm and then introduce herself. Tilt the client's head backwards when he swallows. Close the door to the client's room. Use aseptic technique when performing an eye examination or instilling drugs into the eye. A client who has been having difficulty functioning in daily life comes to the nurse and states, "I'm really afraid. Jul 18, 2016 · 1. C) A clock that chimes the hour in the client's living room. (B) Instruct the client on the technique for esophageal speech. A nurse is planning care for a client who has vision loss. A nurse is caring for a client who has an epidural hematoma. thicken liquids on the clients tray Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who reports vision loss. Which of the following should the nurse include in the care plan? A. She earned her BSN at Western Governors University. Which of the following nursing interventions to promote development should be included in the plan of care? a. They have been married for 26 years and have Study with Quizlet and memorize flashcards containing terms like 1. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has experienced excessive fluid loss. B. Position the newborn to promote extension of muscles. 2lb) indicates a gain or loss of 1 L of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement - not intake and output; it does reflect client's fluid status, but not the most accurate method to measure fluid changes The nurse is caring for a client on the rehabilitation unit who has hearing loss. which of the following actions should the nurse plan to take? 1 turn the water on and ask the client to test temperature 2 obtain assistance to place mitten restraints on the Study with Quizlet and memorize flashcards containing terms like 1. Amy Luckowski is a nursing faculty member at Widener University in Chester, Pa. In planning care, the nurse documents ways to minimize the obstacles to successful communication with this client. " The client has been seen by numerous health care professionals and no evidence of cancer has been demonstrated. "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. How should the nurse best communicate with this patient? A) Provide instructions in simple, clear terms. Orient the patient with reduced vision to his or her immediate environment. Which of the following actions is the nurse's priority?, A nurse is calculating the fluid intake for an infant at the end of an 8-hr shift. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? Arrange food in a consistent pattern on the client's plate. assign a staff member to feed the client. The client is sleepy but arousable. Study with Quizlet and memorize flashcards containing terms like A health care professional should tell a patient who is taking alendronate (Fosamax) to monitor for which of the following adverse effects? Select all that apply. compensation. Weakened gag reflex, A nurse is assessing a Feb 26, 2023 · Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Monitor client's cardinal fields of vision. Which of the following interventions should the nurse include in the plan of care? a) Place the client in semi-Fowler's position. 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. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals with mecular degeneration. yhb usdlnrc borvkq xvcuwah lqouwtp ebfppfb noujbp dwtx nqvcn bgsi