The nurse is preparing to assess a client's near vision. The nurse would use which piece of equipment for the assessment?

Snellen chart

Penlight

Magazine

Ophthalmoscope

Answer and Explanation

The Correct Answer is C

A) Snellen chart:

The Snellen chart is used to assess distance vision, not near vision. It consists of letters or symbols arranged in rows, with the client typically asked to read from a specific distance to test visual acuity.

B) Penlight:

A penlight is primarily used to assess pupillary reactions and near vision tasks such as accommodation. It helps examine how the pupils respond to light and how well the eyes focus on near objects.

C) Magazine:

A magazine or similar reading material is commonly used to assess near vision. Clients are asked to read the text at a comfortable distance, evaluating their ability to focus on close-up objects and the clarity of their vision.

D) Ophthalmoscope:

An ophthalmoscope is used to examine the interior structures of the eye, such as the retina and optic nerve head. It is not used for assessing near vision but rather for diagnosing conditions affecting the eye's internal structures.

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Correct Answer is D

Explanation

Stage I: Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin. There is no break in the skin, but it may appear red and warm to the touch. It is considered the mildest form of pressure injury, signaling the beginning of potential skin damage.

B) Stage III: Stage III pressure ulcers involve full-thickness skin loss. This means that the damage extends through the dermis into the subcutaneous tissue. There may be visible fat, but bone, tendon, and muscle are not exposed. These ulcers are deeper and more serious than the scenario described.

C) Stage IV: Stage IV pressure ulcers are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. The presence of slough or eschar may be present on some parts of the wound bed, and these ulcers are deep, often with extensive damage and infection.

D) Stage II: Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. They present as shallow, open ulcers with a red-pink wound bed, without slough. They may also appear as intact or open/ruptured serum-filled blisters, which matches the description given in the scenario. This stage represents a more significant injury than Stage I but does not extend into the deeper layers of skin and tissue as in Stage III and IV.

A. Size B. Consistency C. Shape D. Color

Correct Answer is D

Explanation

A) Size:

When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.

B) Consistency:

The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.

C) Shape:

Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.

D) Color:

Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.

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The nurse is preparing to assess a client's near vision. The nurse would use which piece of equipment for the assessment?

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Naxlex Comprehensive Predictor Exams

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

Correct Answer is D

Explanation

The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

Correct Answer is D

Explanation

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