The nurse is preparing to assess the visual acuity of a patient.
How should the nurse proceed?
Determine the patient's ability to read newsprint at a distance of 20 inches.
Ask the patient to read the print on a handheld Jaeger card.
Perform the confrontation test.
Use the Snellen chart positioned 20 feet away from the patient.
The Correct Answer is D
Choice A rationale
Reading newsprint at 20 inches assesses near vision, but it is not the standard clinical method for comprehensive visual acuity assessment. While it can provide some insight into the patient's functional near vision, a more precise and standardized tool like a Jaeger card or specific near vision charts are preferred for accurate diagnostic evaluation.
Choice B rationale
The Jaeger card is specifically designed to assess near visual acuity, typically held at 14 inches (35 cm) from the eye. While useful for evaluating reading vision, it does not provide information about distance visual acuity, which is a primary component of a comprehensive eye examination and is assessed using a Snellen chart.
Choice C rationale
The confrontation test assesses peripheral vision, not central visual acuity. It involves the examiner bringing fingers or objects into the patient's field of vision from various directions. While an important part of a complete eye examination to detect visual field defects, it does not quantify the sharpness of central vision.
Choice D rationale
The Snellen chart is the gold standard for assessing distance visual acuity. Positioning it 20 feet away standardizes the testing distance, allowing for accurate measurement of visual acuity as a fraction (e.g., 20/20). This provides a reliable and reproducible measure of central vision, critical for diagnosing and monitoring visual impairments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
The aortic valve, located between the left ventricle and the aorta, is best auscultated at the second intercostal space (ICS) along the right sternal border. This anatomical landmark allows for optimal sound transmission as blood is ejected from the left ventricle into the systemic circulation, enabling clear identification of S2 heart sounds and potential aortic murmurs.
Choice B rationale
The pulmonic valve, positioned between the right ventricle and the pulmonary artery, is most clearly heard at the second intercostal space (ICS) along the left sternal border. This specific location facilitates the detection of sounds associated with blood flow from the right ventricle into the pulmonary circulation, aiding in the assessment of right heart function and conditions like pulmonary hypertension.
Choice C rationale
The tricuspid valve, situated between the right atrium and the right ventricle, is best auscultated at the fourth intercostal space (ICS) along the left sternal border. This site is optimal for assessing the flow of deoxygenated blood into the right ventricle, allowing for the detection of murmurs related to tricuspid regurgitation or stenosis, and evaluating right heart filling.
Choice D rationale
The mitral valve, located between the left atrium and the left ventricle, is most accurately assessed at the fifth intercostal space (ICS) at the left midclavicular line (MCL). This apex beat location is crucial for hearing sounds associated with the filling of the left ventricle and detecting murmurs indicative of mitral valve prolapse, regurgitation, or stenosis, reflecting left heart function.
Correct Answer is B
Explanation
Choice A rationale
A 10-15 degree angle is used for intradermal injections, where the medication is deposited just beneath the epidermis, creating a bleb or wheal. This shallow angle ensures the medication remains within the superficial layers of the skin for diagnostic purposes like allergy testing.
Choice B rationale
Intramuscular injections are administered at a 90-degree angle to ensure the needle penetrates deeply into the muscle tissue, bypassing the subcutaneous layer. This angle facilitates rapid absorption into the well-vascularized muscle and minimizes the risk of medication leakage into the subcutaneous tissue or irritation.
Choice C rationale
A 45-degree angle is typically used for subcutaneous injections, where the medication is deposited into the adipose tissue beneath the dermis. This angle is chosen to avoid injecting into muscle while still reaching the subcutaneous layer for systemic absorption.
Choice D rationale
A 60-degree angle is not a standard injection angle for common parenteral routes. The primary angles used for injections are 10-15 degrees (intradermal), 45 degrees (subcutaneous), and 90 degrees (intramuscular). Deviating from standard angles can compromise medication delivery and patient safety.
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