A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Position the client 3 meters (10 feet) away from the chart

Document the largest line the client can read on the chart

Instruct the client to begin the assessment with both eyes open

Begin by testing the client while they are wearing glasses

Answer and Explanation

The Correct Answer is D

To test visual acuity using a Snellen chart, the nurse should have the patient wear glasses or contact lenses if they normally wear them . The patient should stand 20 feet from the chart . The nurse should tell the patient to first cover the right eye, then left eye, and lastly read the chart with both eyes .

The other options are not correct because:

a). The client should be positioned 20 feet away from the chart, not 3 meters (10 feet).

b) The nurse should document the smallest line the client can read accurately on the chart, not the largest line.

c) The nurse should instruct the client to begin the assessment by covering one eye and reading aloud the letters on the chart, beginning at the top and moving toward the bottom

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Correct Answer is A

Explanation

a. "Many people have colostomies and they live full lives."

Explanation:

The correct answer is a. "Many people have colostomies and they live full lives."

When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and oﬀers hope to the client.

Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.

Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.

Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.

By responding with the statement that many people live full lives with colostomies, the nurse oﬀers support, normalizes the client's experience, and promotes a positive outlook for the client's future.

A. "I feel tired all the time." B. "I have noticed that my fingernails are becoming thicker." C. "I have to go to the bathroom all the time." D. "I notice that my hands are always shaky."

Correct Answer is A

Explanation

A hemoglobin (Hgb) level of 8.8 mg/dL indicates anemia, which is a decrease in the oxygen-carrying capacity of the blood. Fatigue and tiredness are common symptoms of anemia. When the body does not have enough hemoglobin to transport oxygen eﬀectively, it can lead to feelings of fatigue and a lack of energy.

The other options are not directly associated with a low hemoglobin level:

b) "I have noticed that my fingernails are becoming thicker." Thicker fingernails are not typically associated with a low hemoglobin level. Changes in fingernails can be atributed to various factors, but they are not directly related to anemia.

c) "I have to go to the bathroom all the time." Frequent urination is not typically associated with a low hemoglobin level. It can be related to other factors such as urinary tract infections, diabetes, or diuretic use, among others.

d) "I notice that my hands are always shaky." Hand tremors are not directly associated with a low hemoglobin level. Tremors can have various causes, such as neurological conditions, medication side eﬀects, or excessive caﬀeine intake, but they are not directly linked to anemia.

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A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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