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lt35722 lt35722
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A month ago
A client with diabetic retinopathy is admitted after suffering a traumatic brain injury. What nursing interventions are indicated? (Select all that apply.)
1. Assess the client's level of vision.
2. Frequently reorient the client to the environment.
3. Defer the visual portions of neurological exams.
4. Keep the room lights dimmed.
5. Obtain teaching material written in braille.
Textbook 

High-Acuity Nursing


Edition: 6th
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Lighting2551Lighting2551
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A month ago
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More questions for this book are available here
The answer is 1, 2
Rationale:
1. The nurse should conduct an initial assessment of the client's level of vision. This information may be available from the client or may be obtained from the family.
2. The client with visual impairments should be reoriented to the environment as often as necessary to ensure safety and comfort.
3. Neurological examination may be altered by retinopathy. Automatically deferring this portion of the exam is incorrect as levels of vision vary widely.
4. The room lights should be kept at a level that supports both the client's vision and the therapeutic milieu. This will vary with client and treatment.
5. Until the nurse has assessed the client's level of vision, it is impossible to determine if special material will be required. Even if the client is totally blind, the nurse must first assess whether the client can read braille.
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lt35722 Author
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A month ago
I appreciate what you did here, answered it right Smiling Face with Open Mouth
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Yesterday
This site is awesome
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2 hours ago
Good timing, thanks!
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