Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability?
"Since you are older, how bad is your eyesight?"
"Are you able to read the menu to order your own meals?"
"What recreational activities do you enjoy?"
"Do you read more than one book in a year?"
The Correct Answer is B
A. "Since you are older, how bad is your eyesight?": This question is age-biased and vague, focusing on chronological age rather than functional ability. It does not provide concrete information about how vision impairment affects daily self-care activities, making it less useful for planning care.
B. "Are you able to read the menu to order your own meals?": This question directly assesses the patient’s functional vision in a practical context, highlighting how visual alterations impact an essential self-care activity—making choices about nutrition. It provides actionable information for the nurse to identify needs for assistance or adaptive strategies.
C. "What recreational activities do you enjoy?": While this question explores lifestyle and interests, it does not specifically identify limitations in self-care caused by vision problems. It may inform quality-of-life interventions but is secondary to evaluating functional deficits.
D. "Do you read more than one book in a year?": This question assesses reading habits rather than the patient’s ability to perform daily self-care tasks. It does not accurately capture functional impairment or its effect on independence, limiting its relevance for nursing assessment of visual deficits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Suspected deep tissue injury: Suspected deep tissue injuries present as a purple or maroon localized area of intact skin or a blood-filled blister, indicating underlying tissue damage. These injuries are often more severe than stage 1 and involve deeper layers than the epidermis, unlike the intact red skin seen.
B. Stage 2 pressure injury: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis, appearing as a shallow open ulcer or blister. The presence of an open wound differentiates it from the intact skin observed in this patient, making stage 2 inconsistent.
C. Stage 1 pressure injury: Stage 1 pressure injuries are characterized by localized, nonblanchable erythema of intact skin, usually over a bony prominence. The redness indicates early tissue damage while the epidermis remains intact, representing the earliest detectable stage of pressure injury development.
D. Unstageable pressure injury: Unstageable pressure injuries involve full-thickness tissue loss in which the base of the wound is covered by slough or eschar, obscuring the depth of tissue damage. Since the skin in this patient is intact and visible, this classification is inaccurate.
Correct Answer is B
Explanation
A. Ask the patient to sit about 4 ft away facing the nurse: The assessment of extraocular movements (EOM) requires close observation of the patient’s eye tracking and alignment. Sitting too far away, such as 4 feet, may make it difficult to accurately detect subtle deviations, nystagmus, or limitations in gaze. Proper assessment distance is usually around 12–24 inches.
B. Use a penlight approximately 1 ft away from the patient's face and move it slowly in all 6 directions: This technique aligns with the standard EOM assessment. The nurse instructs the patient to follow a target (penlight or finger) through the six cardinal positions of gaze: up, down, left, right, and diagonals. Moving the target slowly allows for observation of smooth pursuit, symmetry, and potential deficits in cranial nerves III, IV, and VI.
C. Ask the patient to cover one eye with their hand: Covering one eye is part of the cover-uncover test, which assesses for strabismus or phorias, not general EOM. While it can provide information on ocular alignment, it does not evaluate full extraocular muscle function through the six cardinal positions of gaze.
D. Move a penlight in a circular motion 1 ft away in front of the patient's eyes: Moving the penlight in a circular motion is not appropriate for EOM assessment, as it does not systematically test each extraocular muscle or cranial nerve. Circular motion may obscure deficits in specific directions of gaze and can result in incomplete assessment of ocular motor function.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.