A nurse is preparing to assess a 4-year-old child’s visual acuity. Which of the following actions should the nurse plan to take?
Use a tumbling E chart for the assessment.
Test the child without glasses before testing with glasses.
Position the child 4.6 meters (15 feet) from the chart.
Assess both eyes together first, then each eye separately.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale
The tumbling E chart is used for visual acuity assessment in children who cannot read letters, such as those who are too young or have language barriers. It involves identifying the direction of the letter “E” in various orientations.
Choice B rationale
Testing the child without glasses before testing with glasses is not the standard procedure for visual acuity assessment. The correct approach is to test with the child’s usual corrective lenses if they have them.
Choice C rationale
The standard distance for visual acuity testing using a chart is 3 meters (10 feet) for children, not 4.6 meters (15 feet)9.
Choice D rationale
Assessing each eye separately first, then both eyes together, is the correct procedure for visual acuity testing. This ensures accurate measurement of each eye’s visual acuity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
The correct answers are Choices C, D, and E.
Choice A rationale
Obtaining a throat culture is not recommended for a child with epiglottitis due to Haemophilus influenzae type B because it can cause further airway obstruction and distress.
Choice B rationale
Inspecting the epiglottis is not advisable as it can cause further airway obstruction and distress. Visualization of the epiglottis should be done in a controlled environment, such as an operating room, by a specialist.
Choice C rationale
Beginning droplet precautions is essential for preventing the spread of Haemophilus influenzae type B, which is transmitted through respiratory droplets.
Choice D rationale
Monitoring oxygen saturation is crucial for assessing the child’s respiratory status and ensuring adequate oxygenation.
Choice E rationale
Initiating IV access is necessary for administering medications and fluids to manage the child’s condition effectively.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Increased capillary refill time is not typically associated with hypoglycemia. It may indicate poor peripheral circulation but is not a common sign of low blood sugar levels.
Choice B rationale
Decreased appetite is not typically associated with hypoglycemia. Hypoglycemia usually causes symptoms such as shakiness, sweating, and confusion.
Choice C rationale
Thirst is not typically associated with hypoglycemia. It is more commonly a symptom of hyperglycemia (high blood sugar levels)9.
Choice D rationale
Shakiness or tremors are common signs of hypoglycemia. When blood sugar levels drop, the body responds by releasing adrenaline, which can cause shakiness.
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