A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?

Full vision loss in at least one eye

The best-corrected vision in the better eye of 20/200 or less

Inability to see clearly from 200 feet away without corrective lenses

Bilateral visual impairment of 20/60 or greater

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because full vision loss in one eye does not necessarily mean that the person is legally blind. Legal blindness depends on the visual acuity and visual field of both eyes.

Choice B Reason: This is correct because legal blindness is defined by the World Health Organization (WHO) as having a visual acuity of 20/200 or worse in the better eye with the best possible correction, such as glasses or contact lenses. This means that the person can see at 20 feet what a normal person can see at 200 feet.

Choice C Reason: This is incorrect because inability to see clearly from 200 feet away without corrective lenses may indicate nearsightedness or myopia, but not legal blindness. Nearsightedness can be corrected with lenses or surgery.

Choice D Reason: This is incorrect because bilateral visual impairment of 20/60 or greater does not meet the criteria for legal blindness. Visual impairment is defined by WHO as having a visual acuity of less than 20/60 but better than 20/200 in the better eye with the best possible correction.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A Reason: A distended bladder is one of the most common triggers of autonomic dysreflexia, which is a life-threatening condition that occurs in clients with spinal cord injuries above T-6. The bladder becomes overfilled and stimulates the sympathetic nervous system, causing vasoconstriction and hypertension.

Choice B Reason: A severe headache is one of the most common symptoms of autonomic dysreflexia, caused by the increased blood pressure in the brain. The headache may be accompanied by blurred vision, sweating, flushing, or anxiety.

Choice C Reason: An elevated blood pressure is the hallmark sign of autonomic dysreflexia, which can reach dangerously high levels and cause stroke, seizure, or death. The blood pressure may rise up to 300/160 mmHg or higher.

Choice D Reason: Nasal congestion is another possible trigger of autonomic dysreflexia, as it stimulates the nasal mucosa and activates the sympathetic nervous system. Other potential triggers include bowel impaction, skin irritation, tight clothing, or temperature changes.

A. The lesion is asymmetrical and dark brown or black B. The lesion has a high risk for metastasis C. The skin around the lesion is warm and red D. The lesion is in an area that is frequently exposed to sunlight E. The lesion is painful

Correct Answer is ["A","B","D"]

Explanation

Choice A Reason: This is correct because melanoma is a type of skin cancer that arises from melanocytes, which are cells that produce pigment. Melanoma lesions are often irregular in shape and color, and may have different shades of brown or black.

Choice B Reason: This is correct because melanoma is a very aggressive and invasive type of skin cancer that can spread quickly to other parts of the body through the blood or lymphatic system. Melanoma has a high mortality rate if not detected and treated early.

Choice C Reason: This is incorrect because warm and red skin around a lesion may indicate inflammation or infection, but not necessarily melanoma. Melanoma lesions may have other signs, such as bleeding, itching, or ulceration.

Choice D Reason: This is correct because melanoma is associated with exposure to ultraviolet (UV) radiation from sunlight or artificial sources, such as tanning beds. UV radiation can damage the DNA of melanocytes and cause them to grow abnormally.

Choice E Reason: This is incorrect because melanoma lesions are usually not painful unless they are ulcerated or infected. Pain may be a sign of other types of skin conditions, such as burns, blisters, or cuts.

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A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is ["A","B","C","D"]

Explanation

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics?

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia?

A nurse is caring for a client who has a complete spinal cord injury. Based on the nurse's understanding about the degree of this type of injury, what can the nurse expect will be the client's level of function?

A client arrives to the emergency department after losing consciousness during a soccer game. Which of the following actions should the nurse take first?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

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A client arrives with an upper respiratory infection and complains of otalgia, malaise, and nasal drainage. The client's temperature is 100.7 F. Which of the following will the nurse anticipate providing to the client?

A nurse is performing a Weber test on a client who reports difficulty hearing in his left ear. The client informs the nurse that he can hear the tone louder in his left ear. Which of the following does this result indicate?