A nurse is performing a focused assessment for a client's vision. What visual assessment is the nurse making when she extends her hand for the client to shake?

Depth perception

Peripheral vision

Color deficit

Double vision

Answer and Explanation

The Correct Answer is B

Choice A Reason: Depth perception is the ability to judge the distance and position of objects in three-dimensional space. Depth perception is assessed by asking the client to touch the tip of a pen or pencil held by the nurse, or by using a stereopsis test.

Choice B Reason: Peripheral vision is the ability to see objects and movements outside the direct line of vision. Peripheral vision is assessed by asking the client to shake the hand of the nurse, who stands at an angle to the client's side, or by using a confrontation test.

Choice C Reason: Color deficit is the inability to distinguish certain colors or shades of colors. Color deficit is assessed by asking the client to identify numbers or shapes on a color plate test, such as the Ishihara test.

Choice D Reason: Double vision is the perception of two images of a single object. Double vision is assessed by asking the client to cover one eye and look at an object, then switch eyes and compare the images, or by using a cover-uncover test.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because rotating nursing staff may not provide emotional support for the client who is rehabilitating from major burns. The client may benefit from having consistent and familiar staff who can establish rapport and trust with him. The nurse should assign staff who are experienced and comfortable with burn care and who can communicate effectively and empathetically with the client.

Choice B Reason: This is incorrect because keeping family members aware of his condition may not provide emotional support for the client who is rehabilitating from major burns. The client may have privacy or confidentiality concerns or may not want his family members to see him in his current state. The nurse should respect the client's wishes and preferences regarding family involvement and obtain his consent before sharing any information.

Choice C Reason: This is correct because talking with the client during wound care can provide emotional support for the client who is rehabilitating from major burns. Wound care can be painful and stressful for the client, so the nurse should use therapeutic communication skills to distract, reassure, and encourage him. The nurse should also explain the procedures and rationale for wound care and allow the client to express his feelings and concerns.

Choice D Reason: This is incorrect because assigning assistive personnel to keep his room neat and clean may not provide emotional support for the client who is rehabilitating from major burns. The client may appreciate a clean environment, but he may also need more direct and personal contact with the nurse. The nurse should spend time with the client and provide holistic care that addresses his physical, psychological, social, and spiritual needs.

A. Heart rate 122/min B. Urinary output 25 ml/hr C. Pain of 6 on a scale of 0 to 10 D. Difficulty swallowing

Correct Answer is D

Explanation

Choice A Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection.

Choice B Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation.

Choice C Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions.

Choice D Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.

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A nurse is performing a focused assessment for a client's vision. What visual assessment is the nurse making when she extends her hand for the client to shake?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Correct Answer is C

Explanation

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Correct Answer is 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 assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?

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A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take?

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. Which of the following findings is consistent with manifestations of cataracts?

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?

A nurse provides education to a client recently diagnosed with macular degeneration. Which of the following statements made by the client requires reinforcement of education by the nurse?