12. When a nurse shines a penlight into an elderly client's eyes to check pupil reaction, the nurse notes that one of the eyes is very cloudy and the pupil does not react. The nurse should:
12. When a nurse shines a penlight into an elderly client's eyes to check pupil reaction, the nurse notes that one of the eyes is very cloudy and the pupil does not react. The nurse should:
. Check vision in the cloudy eye.
. Notify the MD for CT evaluation.
. Keep the room lights dim.
. Restrict dietary protein.
Test-Taking Tip
The stem and correct option include the same world—"cloudy."
Content Area: Geriatrics, Sensory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
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Answer 1 is correct because these are signs of cataracts, which can affect the client's vision. Answer 2 is incorrect because these are signs of cataracts. A CT scan is not needed. Answer 3 is incorrect because these are signs of cataracts. Increased lighting is generally needed to assist with vision, not decreased lighting. Answer 4 is incorrect because these are signs of cataracts. Management is not related to dietary protein.