During a community eye screening, the practical nurse (PN) asks a client to identify the smallest letter that can clearly be read on the Snellen vision chart while standing on a line that is 20 feet from the chart. The client covers the right eye and reads the chart. The PN documents "20/20." Which action should the PN take next?

Use a penlight to observe the pupillary response to light and document the findings.

Tell the client to step to the next marked line, keep the right eye covered, and repeat the procedure.

Instruct the client to cover the left eye and repeat the procedure while standing in the same spot.

Advise the client to meet with a healthcare provider about the need for corrective lenses.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Use a penlight to observe the pupillary response to light and document the findings: Assessment of pupillary response evaluates cranial nerve II and III function and is part of a broader neurological or eye exam. However, the immediate next step after testing one eye for visual acuity is to assess the other eye under the same conditions to obtain a complete and comparable evaluation.

B. Tell the client to step to the next marked line, keep the right eye covered, and repeat the procedure: Changing the client’s position alters the standardized testing distance of 20 feet, which is essential for the validity of Snellen visual acuity results. Moving closer would distort the measurement and does not follow proper testing protocol.

C. Instruct the client to cover the left eye and repeat the procedure while standing in the same spot: Visual acuity must be assessed separately for each eye to identify unilateral or bilateral deficits. Maintaining the same distance ensures consistency and accuracy of results. Testing the other eye immediately after completing the first eye follows standard screening procedure.

D. Advise the client to meet with a healthcare provider about the need for corrective lenses: A result of 20/20 indicates normal visual acuity in the tested eye, so there is no immediate indication for referral. Recommendations for corrective lenses should be based on abnormal findings or functional complaints rather than normal screening results.

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Correct Answer is A

Explanation

Rationale:

A. Posturing with extension of the extremities: Decerebrate posturing, characterized by rigid extension of the arms and legs, indicates severe brain injury or dysfunction of the brainstem. This abnormal response reflects significant neurologic compromise and is associated with poor prognosis, requiring immediate attention and continued monitoring.

B. Moaning with a grimace facial expression: Vocalization and facial grimacing represent purposeful or reflexive responses to pain. While this indicates some level of neurological responsiveness, it does not reflect severe neurologic deterioration as posturing does.

C. Withdrawal from the stimulus: Flexion or withdrawal from painful stimuli is a normal protective reflex mediated by the spinal cord and indicates preserved motor function. This response is expected in clients with intact neurologic pathways.

D. Increased respiratory rate: Tachypnea may occur due to pain, anxiety, or other physiologic responses but does not specifically indicate severe neurologic injury. Respiratory changes alone are insufficient to identify critical neurologic compromise without other signs such as abnormal posturing.

A. Hemoglobin 8.9 grams/dL (89 g/L). B. Potassium 3.4 mEq/L (3.4 mmol/L). C. Sodium 130 mEq/L (130 mmol/L). D. Blood urea nitrogen 20 mg/dL (7.14 mmol/L).

Correct Answer is A

Explanation

Rationale:

A. Hemoglobin 8.9 grams/dL (89 g/L): This value is significantly below the normal range of 12–16 g/dL, indicating anemia, likely from perioperative blood loss. Low hemoglobin can compromise oxygen delivery to tissues, increase risk for hypoxia, and cause tachycardia, hypotension, or dizziness, which are critical safety concerns for a postoperative client.

B. Potassium 3.4 mEq/L (3.4 mmol/L): This is slightly below the normal range of 3.5–5.0 mEq/L, indicating mild hypokalemia. While important for cardiac and neuromuscular function, the degree of deviation is less immediately life-threatening than severe anemia in the early postoperative period.

C. Sodium 130 mEq/L (130 mmol/L): Hyponatremia below the normal range of 136–145 mEq/L can lead to neurological changes such as confusion or seizures. However, in the context of immediate postoperative safety, the oxygen-carrying deficit from low hemoglobin has a more direct impact on vital organ perfusion.

D. Blood urea nitrogen 20 mg/dL (7.14 mmol/L): This value is at the upper limit of the normal range (10–20 mg/dL) and may reflect mild renal stress or dehydration but does not pose an immediate safety risk compared with severe anemia post-surgery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) assists with a full neurological evaluation of a client with severe head trauma. Which client response to a painful stimulus indicates a significant neurologic problem?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

After repositioning an older adult client from the right to the left side, the practical nurse (PN) observes a reddened area on the client's right hip over the area of the greater trochanter. Which action should the PN take?

Which method is best for the practical nurse (PN) to use in determining early development of ascites in the client?

The practical nurse (PN) is performing a focused assessment of an adolescent girl's spine, the PN should ask the adolescent to assume which position?

An older adult male client reports nocturia with difficulty starting his urine stream. Which focused assessment should the practical nurse (PN) perform to obtain further information?

The practical nurse (PN) is performing a pain assessment on a client. Which factor(s) have been shown to have an effect on a client's perception of pain and will most likely increase the perception of pain? Select all that apply.

The practical nurse (PN) is auscultating the lung fields of a client exhibiting a low-pitched, grating sound during inspiration and expiration. The PN notes that coughing does not clear the sound. Which term best describes this lung sound?

The practical nurse (PN) is interviewing a client with a neuromuscular disease. Which question(s) is/are best for the PN to ask to assess for "disuse syndrome?" Select all that apply.