A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

"I should get a longer cord for my telephone."

"I should place a throw rug over electrical cords."

"It is a good idea to use the handrails in the bathroom."

"I should use chairs without armrests."

Answer and Explanation

The Correct Answer is C

Choice a reason:
Getting a longer cord for the telephone may reduce the risk of tripping over a short cord but could potentially introduce new tripping hazards if not managed properly. It's important to keep cords secured and out of walkways to prevent falls.

Choice b reason:
Placing a throw rug over electrical cords is not advisable as it can create a tripping hazard. Rugs should be secured with non-slip backing and kept away from high-traffic areas to prevent falls.

Choice c reason:
Using handrails in the bathroom is a recommended safety measure to prevent falls. Bathrooms can be slippery, and handrails provide support and stability for residents when moving around in this area.

Choice d reason:
Using chairs without armrests is not a recommended practice for fall prevention. Chairs with armrests can aid residents in safely sitting down and standing up, providing support and reducing the risk of falls.

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Correct Answer is C

Explanation

Choice A Reason:
Positioning the arm below waist level is not recommended when measuring blood pressure. It can result in an inaccurate reading, typically showing a higher blood pressure due to the effects of gravity on the blood column. The arm should be positioned at heart level for an accurate measurement.

Choice B Reason:
While palpating the radial artery to confirm a pulse is present is part of the overall assessment of circulation, it is not a necessary step immediately before measuring blood pressure. The focus should be on ensuring the client is in the correct position and is relaxed to avoid any factors that might artificially alter the blood pressure reading.

Choice C Reason:
Asking the client to sit quietly in a chair for 5 minutes is the correct procedure before measuring blood pressure. This allows the client's heart rate and blood pressure to stabilize, providing a more accurate measurement. Any activity or stress can temporarily raise blood pressure, so this quiet time is crucial.

Choice D Reason:
The arm selected for blood pressure measurement should not be covered with clothing. Clothing can constrict the blood pressure cuff and interfere with the accuracy of the reading. The cuff should be placed on bare skin to ensure it inflates and deflates correctly and that the stethoscope can accurately detect the sounds of the blood flow.

A. Peripheral vision. B. External eye structures. C. Distant vision. D. Near vision.

Correct Answer is C

Explanation

Choice A reason:
Peripheral vision is the ability to see objects and movement outside of the direct line of vision. This type of vision is assessed using different methods, such as confrontation visual field testing, where the examiner moves objects into the patient's side vision from different angles. Standing 20 feet away from a chart would not be the appropriate method to assess peripheral vision.
Choice B reason:
The assessment of external eye structures involves examining the physical appearance and condition of the eyelids, sclera, conjunctiva, and surrounding areas. This is typically done at a close range and does not require the patient to stand at a distance from a chart. The nurse would inspect these structures directly, often with the aid of a penlight for better visibility.

Choice C reason:
Distant vision is the ability to see objects far away, and it is what the nurse is preparing to assess when the client is asked to stand 20 feet from a chart. This distance is standard for the Snellen eye chart, which is used to measure visual acuity. The chart has rows of letters that decrease in size, and the patient is asked to read the smallest line of letters they can see clearly. The Snellen chart is the most common method used by eye doctors to measure visual acuity.
Choice D reason:
Near vision is the ability to see objects that are close to the eyes clearly. It is assessed using different charts, such as the Jaeger eye chart, which contains blocks of text in various type sizes. The patient is asked to read the text at a close range, typically around 14 inches, not 20 feet. Therefore, standing 20 feet away from a chart would not be the method to assess near vision.

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A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has arrived at the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?

Correct Answer is C

Explanation

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

Correct Answer is C

Explanation

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