The nurse is preparing to assess the visual acuity of an adult patient, which of the following assessment should the nurse use for visual acuity

Perform the conduntation test

Ask the patient to read the point on a handheld larger card

Determine the patient's ability to read newsprint at a distance of 12 to 1 mche

Use the Snellen chart positioned 20 feet away from the patient

Answer and Explanation

The Correct Answer is D

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

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Correct Answer is C

Explanation

A. Discuss that a light will be directed at the neck to observe for pulsations of the artery:

This choice is incorrect. Directing light at the neck is not a standard method for assessing carotid artery pulsations. The carotid artery is usually assessed by palpation to feel the pulse rather than visual observation.

B. Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates:

This choice is incorrect. Auscultation is typically not used to assess carotid artery pulsations. Palpation (feeling the pulse) is the primary method used for this assessment.

C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude:

This choice is correct. Palpating both carotid arteries simultaneously allows the nurse to compare the amplitude (strength) of the pulses. This comparison helps in assessing the symmetry of the pulses and ensures there are no significant differences between the two sides, which could indicate vascular abnormalities.

D. Show the client the diaphragm of the stethoscope that will be placed on the neck:

This choice is incorrect. The diaphragm of the stethoscope is not typically used for palpating pulses. Palpation involves using the fingertips to feel the pulse and assess its strength and regularity.

A. Inform the client that his breast enlargement is benign, and normal for a man of his age B. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. C. Recommend that he alter his diet to include fewer fats and more lean proteins D. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

Correct Answer is B

Explanation

A. Inform the client that his breast enlargement is benign, and normal for a man of his age:

This choice is not appropriate because while gynecomastia can be benign, it should not be assumed without a proper medical evaluation. Gynecomastia can have various causes, including hormonal imbalances or underlying medical conditions. It's crucial to identify the cause through a medical assessment.

B. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician:

This is the correct choice. Gynecomastia can indeed be caused by hormonal changes, but it can also be due to medications, certain health conditions, or hormonal imbalances. Therefore, the nurse should recommend a medical evaluation to determine the underlying cause and appropriate management.

C. Recommend that he alter his diet to include fewer fats and more lean proteins:

This choice is not relevant to gynecomastia. Gynecomastia is not typically caused by dietary factors, so altering the diet would not be a suitable response to this situation.

D. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened:

This choice is incorrect. Gynecomastia is not directly associated with prostate enlargement. While both conditions can occur in older men, they are distinct medical issues. Screening for prostate enlargement is not indicated based solely on the presence of gynecomastia. Proper evaluation and assessment of each condition are necessary.

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The nurse is preparing to assess the visual acuity of an adult patient, which of the following assessment should the nurse use for visual acuity

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Correct Answer is B

Explanation

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