The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)
The Correct Answer is ["20"]
The standard distance for a visual acuity test using the Snellen chart is 20 feet. This distance allows for an accurate assessment of how well a person can see the details of the letters on the chart, which is a common method used by eye doctors to measure visual acuity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lymph nodes that feel ropey and rubbery might indicate chronic inflammation or fibrosis. This texture is not typically considered normal. In elderly clients, lymph nodes may become less palpable due to age- related changes, but they should not feel ropey or rubbery. If lymph nodes feel this way, it may warrant further investigation to rule out pathological conditions.
B. In elderly clients, axillary lymph nodes may feel softer and less defined due to fatty tissue changes associated with aging. However, "soft and fatty" should be interpreted cautiously. While some degree of change is normal, nodes should not be excessively soft, nor should they have an abnormal appearance. The key is that they should not be hard, fixed, or tender, which would be indicative of pathology.
C. Enlarged and warm inguinal lymph nodes suggest infection or inflammation rather than a normal finding. In the elderly, while lymph nodes can sometimes be palpable, they should not be enlarged or warm, as this could indicate an underlying condition or infection that requires further evaluation.
D. It is normal for lymph nodes to be non-palpable in many individuals, including older adults. Age- related changes can cause lymph nodes to be less prominent or difficult to palpate. If lymph nodes are non-palpable, it usually means they are not enlarged or abnormal, which is a normal finding, especially if the client is not experiencing any symptoms of infection or other related issues.
Correct Answer is C
Explanation
A. Being oriented x 3 means the client is aware of their name, the current time (or day), and the location (place). In this case, since the client is only able to remember his name and where he is, but not the time, day, or date, this documentation would be incorrect. The client does not meet the criteria for being oriented x 3.
B. Being oriented x 1 means the client is aware of only one aspect of orientation, such as their name. Since the client is able to remember both his name and his location, documenting as oriented x 1 would not fully capture the extent of the client's orientation. The client is oriented to more than one aspect.
C. Being oriented x 2 means the client is aware of two aspects of orientation. In this case, since the client is able to remember his name and his location (but not the time, day, or date), documenting as oriented x 2 accurately reflects his level of orientation.
D. Being oriented x 4 means the client is aware of four aspects: their name, the current time (or day), the date, and the location. Given that the client can only remember his name and location, this
documentation would be incorrect as it does not align with the client’s current state of orientation.
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