In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?

Correct Answer: D

Rationale: Arcus senilis is a condition characterized by a white or gray ring forming around the cornea and does not typically cause visual problems. It is a common and benign condition often seen in older adults. On the other hand, glaucoma, macular degeneration, and cataracts are all eye conditions that can significantly affect vision and lead to visual impairments in older adults. Therefore, in planning safe care for the older adult, the nurse should recognize that Arcus senilis would not cause visual problems unlike the other conditions mentioned.

Correct Answer: C

Rationale: The nursing care for a client in Addisonian crisis, also known as adrenal crisis, should include offering extra blankets and raising the heat in the room to keep the client warm. Addisonian crisis is a life-threatening condition that occurs when the body does not have enough cortisol and aldosterone, which are hormones produced by the adrenal glands. Symptoms of Addisonian crisis include severe weakness, fatigue, abdominal pain, nausea, vomiting, and low blood pressure. By offering extra blankets and raising the room temperature, the nurse can help prevent hypothermia, which can worsen the client's condition. It is important to maintain the client's body temperature to promote comfort and prevent further complications during Addisonian crisis.

Correct Answer: C

Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.

Correct Answer: A

Rationale: Administering oxygen therapy would be the priority intervention in this case because Arthur is experiencing pneumonia with a high fever (39° to 40° C). High fever can lead to increased oxygen demand in the body, and providing supplemental oxygen can help ensure that Arthur is receiving adequate oxygenation to support his respiratory function. Oxygen therapy can also help improve oxygen saturation levels, which may be compromised due to the pneumonia. Therefore, addressing the potential respiratory distress caused by the pneumonia and fever should be the top priority to optimize Arthur's oxygenation levels and respiratory function.

Correct Answer: D

Rationale: A herniated nucleus pulposus at the C4-C5 and C5-C6 interspace typically results in neck and shoulder pain, which can radiate to the scapular region. The herniation at these levels can cause irritation or compression of the cervical nerve roots leading to pain, numbness, tingling, or weakness in the affected areas. Constant, throbbing headaches are not typically associated with this specific diagnosis. Clonus in the lower extremities and numbness of the face are also not common findings related to herniated nucleus pulposus at the cervical spine levels mentioned.