Author Question: The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses ... (Read 103 times)

silviawilliams41 · **on:** Jul 22, 2018

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury?

a. Risk for falls
b. Body image disturbance
c. Social isolation
d. Fear

Question 2

On admitting a patient, the nurse finds a history of myocardial ischemia. What is the most disconcerting dysrhythmia that electrocardiography can reveal for this patient?

a. Sinus bradycardia
b. Sinus dysrhythmias
c. Ventricular tachycardia
d. Atrial fibrillation

kthug · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.

Answer to Question 2

C

Feedback
A Sinus bradycardia would not be of concern for this patient. It is of no clinical significance unless it is associated with signs and symptoms of a decreased cardiac output.
B Sinus dysrhythmia is of no clinical significance unless dizziness occurs with a decreased heart rate.
C Ventricular tachycardia would be the most disconcerting dysrhythmia of the four options. Ventricular tachycardia results in a decreased cardiac output; it may lead to severe hypotension, loss of pulse, and unconsciousness.
D Atrial fibrillation is not as detrimental as ventricular tachycardia.