A client comes to the clinic with concern about being unable to clearly see objects in the distance. The Snellen test results are 20/40 in the right eye and 20/30 in the left eye. Which action should the practical nurse (PN) implement?
Inquire about the impact on activities of daily living.
Document the findings are within normal limits in the medical record.
Move the client until 10 feet away from the chart.
Encourage the client to schedule an appointment with an ophthalmologist.
The Correct Answer is A
Rationale:
A. Inquire about the impact on activities of daily living: Visual acuity of 20/40 and 20/30 indicates reduced distance vision, particularly affecting tasks such as driving, reading signs, or recognizing faces at a distance. Assessing how this impairment affects the client’s daily functioning helps determine the clinical significance and need for intervention.
B. Document the findings are within normal limits in the medical record: Normal visual acuity is 20/20, and values of 20/30 and 20/40 represent diminished visual clarity. Documenting these findings as normal would be inaccurate and could delay appropriate evaluation or intervention. Proper interpretation of the Snellen test is essential for safe clinical decision-making.
C. Move the client until 10 feet away from the chart: The Snellen chart is standardized for use at a distance of 20 feet (or equivalent using mirrors), ensuring consistency and validity of results. Changing the testing distance to 10 feet without appropriate calibration alters the accuracy of the measurement and invalidates the assessment.
D. Encourage the client to schedule an appointment with an ophthalmologist: Referral to an eye specialist may eventually be appropriate, especially if visual impairment affects function. However, the nurse should first assess the impact on the client’s daily activities to determine urgency and guide appropriate follow-up care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Palpation: Palpation is primarily used to assess tactile sensations such as tenderness, masses, or vibrations (tactile fremitus). It does not provide an accurate measure of chest dimensions or the anterior-posterior diameter.
B. Percussion: Percussion is used to evaluate underlying structures, detect fluid, air, or masses, and assess organ borders. While it provides information about density, it does not allow measurement of the chest’s anterior-posterior diameter.
C. Auscultation: Auscultation is used to assess lung and airway sounds, such as breath sounds or adventitious sounds. It provides no visual or dimensional data about chest shape or diameter.
D. Observation: Observation is the correct technique for assessing the anterior-posterior chest diameter. The nurse visually inspects the chest from the side to compare the front-to-back measurement with the transverse diameter. This helps identify abnormalities such as barrel chest, which can be indicative of COPD or other pulmonary conditions.
Correct Answer is A
Explanation
Rationale:
A. Tonsils are observable and covered with a white exudate: White exudate on the tonsils can indicate an acute infection, such as bacterial tonsillitis or streptococcal pharyngitis, which can rapidly progress and cause systemic complications if untreated. Immediate reporting is warranted to ensure timely medical evaluation, potential antibiotic therapy, and prevention of complications
B. Ventral surface of the tongue appears smooth and glistening: A smooth, glistening tongue may reflect nutritional deficiencies, such as vitamin B12 or iron deficiency, but it is generally a chronic finding and not immediately life-threatening. It requires assessment but not urgent intervention.
C. Dorsal surface of the tongue is rough with a white coating: A white coating on the dorsal tongue often represents benign causes, such as oral candidiasis or debris accumulation. While it may require treatment, it is typically not an acute emergency unless accompanied by severe symptoms like dysphagia or systemic infection.
D. Teeth are yellowed and crooked with debris collected in the gaps: Poor dental hygiene and discoloration indicate chronic oral health issues. These findings require preventive education and routine dental care but do not demand immediate medical action.
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