When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, 'visual sensory/perceptual alterations.' This diagnosis is based on which etiology?

Correct Answer: B

Rationale: In the context of a client diagnosed with open-angle glaucoma, the priority nursing diagnosis of "visual sensory/perceptual alterations" is based on the etiology of decreased peripheral vision. This is the correct answer (B) because in open-angle glaucoma, there is a gradual increase in intraocular pressure leading to optic nerve damage. This damage initially affects the peripheral vision before progressing to central vision loss. Therefore, addressing the alteration in peripheral vision is crucial in the care of a client with glaucoma to prevent further visual impairment. Limited eye movement (A) is not the primary etiology for the nursing diagnosis in this case, as glaucoma primarily affects vision due to increased intraocular pressure rather than eye movement restrictions. Blurred distance vision (C) is a common symptom in various eye conditions but is not specific to open-angle glaucoma. Photosensitivity (D) is also not directly related to the etiology of visual sensory alterations in glaucoma. Educationally, understanding the pathophysiology of open-angle glaucoma and its impact on visual function is essential for nurses caring for clients with this condition. Recognizing the priority nursing diagnosis based on the specific etiology of the disease helps in providing targeted and effective care to prevent further vision loss and promote optimal visual health in these clients.

Correct Answer: B

Rationale: In this scenario, the most crucial serum laboratory value for the nurse to monitor in a client with Addison's disease who started taking hydrocortisone is glucose (Option B). Rationale for Option B: Hydrocortisone is a corticosteroid used to replace deficient cortisol in conditions like Addison's disease. Corticosteroids can increase blood glucose levels by promoting gluconeogenesis and decreasing glucose uptake, which can lead to hyperglycemia. Monitoring glucose levels is essential to detect and manage hyperglycemia promptly, especially in pediatric patients who may be more vulnerable to glucose fluctuations. Rationale for Incorrect Options: A) Osmolarity: While changes in osmolarity can occur with certain medical conditions or treatments, monitoring glucose levels would be more directly related to the effects of hydrocortisone therapy in this case. C) Albumin: Albumin levels are important for assessing nutritional status and liver function but are not the most critical parameter to monitor when starting hydrocortisone therapy. D) Platelets: Platelet count is important for assessing clotting function but is not directly impacted by hydrocortisone therapy in the same way that glucose levels are. Educational Context: Understanding the rationale behind monitoring specific laboratory values in patients receiving certain medications is crucial for nurses to provide safe and effective care. In pediatric patients with Addison's disease starting hydrocortisone therapy, nurses must be vigilant in monitoring glucose levels to prevent and manage potential hyperglycemia complications. This educational context emphasizes the importance of individualizing patient care and tailoring monitoring based on the pharmacological effects of specific medications.

Correct Answer: C

Rationale: Rationale: The correct answer is C) Discuss approaches to chronic pain control with the client. Heberden's nodes are a characteristic feature of osteoarthritis, not degenerative joint disease. These nodes are painful and can significantly impact the client's quality of life. Therefore, addressing the client's pain is a priority in their care plan. Option A) Reviewing the client's dietary intake of high-protein foods is not directly related to managing the client's pain associated with Heberden's nodes. While diet can impact joint health, it is not the immediate concern in this scenario. Option B) Notifying the healthcare provider immediately is not necessary in this case as the nurse can first initiate interventions to help alleviate the client's pain. Prompt pain management is crucial for improving the client's comfort and function. Option D) Assessing the client's radial pulses and capillary refill time is important for assessing circulation but is not the priority in addressing the client's current complaint of painful Heberden's nodes. Pain management should be the initial focus to address the client's immediate discomfort. Educational Context: Understanding the manifestations and management of osteoarthritis, including Heberden's nodes, is essential for nurses caring for clients with joint conditions. Effective pain management strategies can significantly improve the client's quality of life and functional ability. Nurses play a key role in assessing, educating, and implementing interventions to address pain in clients with joint diseases like osteoarthritis.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) 0.9 ml. To arrive at this answer, the nurse needs to calculate the dose based on the available concentration of enoxaparin (150 mg/ml) and the prescribed dose of 135 mg. To calculate the volume needed, the nurse can use the formula: Volume (ml) = Dose (mg) / Concentration (mg/ml) Substituting the values: Volume = 135 mg / 150 mg/ml Volume = 0.9 ml Therefore, the nurse should administer 0.9 ml of enoxaparin. Option B) 1 ml is incorrect because administering 1 ml would result in giving slightly more medication than the prescribed dose of 135 mg. Option C) 9 ml is significantly higher than the correct answer and would result in a substantial overdose, posing serious risks to the pediatric patient. Option D) 0 ml is incorrect as it implies not administering any medication, which would be incorrect when a dose of enoxaparin has been prescribed for the patient. Understanding medication calculations and dose conversions is crucial for nurses to ensure accurate and safe administration of medications, especially in pediatric patients where dosages need to be precise to prevent adverse effects. Nurses must be proficient in performing these calculations to deliver effective patient care.

Correct Answer: D

Rationale: In this scenario, the nurse should first palpate the abdomen for tenderness and rigidity. This is important because the client has a history of cirrhosis and ascites, which can lead to complications such as spontaneous bacterial peritonitis (SBP) or gastrointestinal bleeding. Palpating the abdomen can help assess for signs of infection, bleeding, or organ damage, all of which require immediate attention. Option A, evaluating distal capillary refill, is not the priority in this case because the client's current symptoms suggest more urgent issues related to their underlying condition. Checking extremities for bruising and petechiae (Option B) is not as crucial as assessing the abdomen in a client with cirrhosis and ascites. Similarly, examining the pretibial regions for pitting edema (Option C) is less urgent compared to assessing for abdominal tenderness and rigidity in this situation. Educationally, this question highlights the importance of prioritizing assessments based on the client's presenting symptoms and medical history. It reinforces the need for nurses to be able to quickly identify potential complications in clients with chronic conditions and to respond promptly to changes in their condition. This type of critical thinking is essential in providing safe and effective care to pediatric clients with complex health needs.