A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

20 represents the distance you are placed from the chart and 40 represents the distance a normal eye read the chart.

20 represents the distance a normal eye can read and 40 represents the distance your eye read the chart.

20 represents the distance you are placed from the chart and 40 represents the distance your eye read the chart.

40 represents the distance you are placed from the chart and 20 represents the distance a normal eye read the chart.

Answer and Explanation

The Correct Answer is A

A. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye reads the chart:

This is correct. The first number (20) represents the distance in feet the patient is from the Snellen chart. The second number (40) indicates the distance at which a person with normal vision can read the same line. Therefore, 20/40 means that what the patient can read at 20 feet, a person with normal vision can read at 40 feet.

B. 20 represents the distance a normal eye can read and 40 represents the distance your eye reads the chart:

This is incorrect. The first number should represent the distance the patient is from the chart, not the normal eye's reading distance.

C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye reads the chart:

This is incorrect. While the first number is correct (the distance from the chart), the second number should represent the distance a person with normal vision can read the same line, not the patient's distance.

D. 40 represents the distance you are placed from the chart and 20 represents the distance a normal eye reads the chart:

This is incorrect. The standard for visual acuity measurements is that the first number represents the testing distance (usually 20 feet), and the second number represents the distance at which a normal eye can read the line.

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Correct Answer is B

Explanation

A. Improved wound healing:

While silver sulfadiazine is used to promote wound healing by preventing and treating infections in burn victims, this is not an adverse reaction. This is an intended therapeutic effect of the medication.

B. Allergic reaction in patients with sulfa allergies:

Silver sulfadiazine contains sulfa, and patients who have a sulfa allergy may experience an allergic reaction. This can range from mild skin rashes to severe systemic reactions and is considered a significant adverse reaction.

C. Delayed wound healing:

Silver sulfadiazine is generally used to promote wound healing by preventing bacterial infections. Delayed wound healing is not a common adverse reaction but may occur in some cases due to other underlying factors or if the medication is not effective against certain bacteria.

D. Increased risk of infection:

The primary purpose of silver sulfadiazine is to reduce the risk of infection in burn wounds. An increased risk of infection would indicate a failure of the medication, not an adverse reaction. The correct potential adverse reaction is an allergic response in patients with a known sulfa allergy.

A. At the angle of the mandible B. temporal area C. The posterior base of the skull D. Area in front of the ears

Correct Answer is C

Explanation

A) At the angle of the mandible:

Lymph nodes located at the angle of the mandible are the submandibular lymph nodes, not the occipital lymph nodes. These nodes are situated below the jawline and are assessed when looking for infections or abnormalities in the oral cavity and throat.

B) Temporal area:

The temporal area is not a typical location for lymph node palpation. This region is primarily related to the temporal artery and muscles, not to lymph nodes. Thus, palpating for lymph nodes here would not be relevant.

C) The posterior base of the skull:

The occipital lymph nodes are located at the posterior base of the skull, near the nape of the neck. These nodes drain the scalp and are assessed when there are scalp infections or other related conditions.

D) Area in front of the ears:

The lymph nodes in front of the ears are the preauricular lymph nodes. These nodes drain the eyes and the surrounding skin. They are not the occipital lymph nodes, which are situated at the back of the head.

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A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Correct Answer is B

Explanation

At which location would a nurse palpate a client's occipital lymph nodes?

Correct Answer is C

Explanation

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

A nurse measures a patient height and weight and calculate his BMI. Patient BMI is 37. Classify according to this BMI results?

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?