A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?
Position the client 3 meters (10 feet) away from the chart
Document the largest line the client can read on the chart
Instruct the client to begin the assessment with both eyes open
Begin by testing the client while they are wearing glasses
The Correct Answer is D
To test visual acuity using a Snellen chart, the nurse should have the patient wear glasses or contact lenses if they normally wear them . The patient should stand 20 feet from the chart . The nurse should tell the patient to first cover the right eye, then left eye, and lastly read the chart with both eyes .
The other options are not correct because:
a). The client should be positioned 20 feet away from the chart, not 3 meters (10 feet).
b) The nurse should document the smallest line the client can read accurately on the chart, not the largest line.
c) The nurse should instruct the client to begin the assessment by covering one eye and reading aloud the letters on the chart, beginning at the top and moving toward the bottom
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Give directions using simple phrases.
The correct answer is b. Give directions using simple phrases.
Explanation:
When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.
Explanation for the other options:
a. Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.
c. Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.
d. Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client.
In summary, giving directions using simple phrases is an appropriate action when assisting with the plan of care for a client with Alzheimer's disease. This approach promotes effective communication and enhances the client's ability to understand and follow instructions.
Correct Answer is D
Explanation
Answer: D. "Clean the prosthesis using a damp, soapy cloth."
Rationale:
A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.
B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.
C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.
D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.
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