A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?

Full vision loss in at least one eye

The best-corrected vision in the better eye of 20/200 or less

Inability to see clearly from 200 feet away without corrective lenses

Bilateral visual impairment of 20/60 or greater

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because full vision loss in one eye does not necessarily mean that the person is legally blind. Legal blindness depends on the visual acuity and visual field of both eyes.

Choice B Reason: This is correct because legal blindness is defined by the World Health Organization (WHO) as having a visual acuity of 20/200 or worse in the better eye with the best possible correction, such as glasses or contact lenses. This means that the person can see at 20 feet what a normal person can see at 200 feet.

Choice C Reason: This is incorrect because inability to see clearly from 200 feet away without corrective lenses may indicate nearsightedness or myopia, but not legal blindness. Nearsightedness can be corrected with lenses or surgery.

Choice D Reason: This is incorrect because bilateral visual impairment of 20/60 or greater does not meet the criteria for legal blindness. Visual impairment is defined by WHO as having a visual acuity of less than 20/60 but better than 20/200 in the better eye with the best possible correction.

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Correct Answer is A

Explanation

Choice A reason: This is correct because resuming a functional role in society is the ultimate goal for a client in the rehabilitative phase of a burn injury. The rehabilitative phase begins when wound healing is complete and lasts until physical and psychosocial recovery is achieved. The nurse should help the client regain independence, self-esteem, and quality of life by providing education, counseling, referrals, and resources.

Choice B reason: This is incorrect because pain management is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Pain management is important throughout all phases of burn care, but especially during wound healing and scar formation, which can cause itching, tightness, or hypersensitivity. The nurse should assess the client's pain level and administer analgesics, antipruritics, or moisturizers as ordered.

Choice C reason: This is incorrect because providing continued full support to the client is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Providing continued full support to the client can help them cope with physical and emotional challenges, such as scarring, disfigurement, disability, or depression. The nurse should provide emotional support, active listening, positive feedback, and encouragement to the client.

Choice D reason: This is incorrect because preventing infection is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Preventing infection is crucial during wound healing and grafting, which can be compromised by bacterial colonization or contamination. The nurse should monitor the client's vital signs, wound appearance, and laboratory results, and administer antibiotics or antiseptics as ordered.

A. A 40 year old female who drives a motorcycle B. A pregnant female who has high blood pressure C. A 18 year old male who smokes and has a family history of brain cancer D. A 65 year old male client who golfs 3 times a week and drives a golf cart

Correct Answer is A

Explanation

Choice A Reason: This is the correct choice because driving a motorcycle is a high-risk activity that can expose the client to head trauma, especially if they do not wear a helmet. Traumatic brain injury (TBI) is a condition where the brain is damaged by an external force, such as a collision, fall, or assault.

Choice B Reason: This is incorrect because having high blood pressure is not a direct risk factor for traumatic brain injury. High blood pressure can increase the risk of stroke, which is a condition where the brain is damaged by an internal cause, such as a blood clot or hemorrhage.

Choice C Reason: This is incorrect because smoking and having a family history of brain cancer are not risk factors for traumatic brain injury. Smoking and genetic factors can increase the risk of developing brain tumors, which are abnormal growths of cells in the brain.

Choice D Reason: This is incorrect because golfing and driving a golf cart are low-risk activities that do not pose a significant threat to the client's head. Golfing and driving a golf cart may cause minor injuries, such as sprains, strains, or bruises, but not traumatic brain injury.

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A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?

Correct Answer is A

Explanation

Which of the following clients is most at risk for traumatic brain injury?

Correct Answer is A

Explanation

A nurse collects the health history of a 65-year-old client. Which of the following risk factors in the client's history puts the client at the highest risk for embolic stroke?

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

A nurse is caring for a client who has suffered a stroke involving the left hemisphere. Which of the following alterations in function are consistent with this type of stroke?

A client arrives to the clinic with reports of progressive weakness in his lower extremities. Which of the following findings in the client's history is consistent with the client developing Guillain-Barre syndrome?

A client presents to the clinic with complaints of otalgia and muffled sounds. The client is diagnosed with external otitis. Which of the following will the nurse not include in client teaching?

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

When performing an assessment, the nurse observes for bilateral equality. After performing a neurological assessment, which of the following will the nurse document when assessment findings indicate that there is left facial droop?

A nurse reviewing a client's chart reads that the client was observed having a complex partial seizure with automatisms of the face. What does the nurse understand this to mean?