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 ["A","B","D","F"]
Explanation
Answer: A, B, D, F
Rationale:
A. "The ECT procedure will cause you to have a brief seizure.":
This statement is accurate as electroconvulsive therapy (ECT) intentionally induces a controlled seizure, which is thought to positively impact brain chemistry and alleviate symptoms of major depressive disorder. Educating the client about this aspect helps demystify the procedure and reduces anxiety.
B. "You will not be awake during the ECT procedure.":
The client receives general anesthesia before ECT, so they will be unconscious during the procedure. This reassurance can help alleviate fears associated with being awake and experiencing discomfort during the procedure.
C. "You will be placed on a ventilator to help you breathe during the ECT procedure.":
During ECT, clients do not require a ventilator, although they may receive oxygen support. An anesthetic and muscle relaxant are administered, and while the client’s breathing is closely monitored, a ventilator is unnecessary for this brief procedure.
D. "You will probably sleep the rest of the day following the ECT procedure.":
Many clients feel drowsy and need extra rest after ECT due to the effects of anesthesia and the brief seizure. Informing the client helps them prepare for this common effect and sets realistic expectations for their recovery period.
E. "It should only take one ECT treatment to bring you out of your depression.":
ECT is typically given as a series of treatments over several weeks to achieve lasting improvement in depressive symptoms. One treatment alone is usually insufficient, so this statement could mislead the client regarding the treatment plan.
F. "Some clients experience temporary memory loss following ECT therapy.":
Temporary memory loss, especially of recent events, is a known side effect of ECT. This side effect is generally transient but can help the client to be aware of this possibility, helping them to anticipate and manage any concerns post-treatment.
Correct Answer is C
Explanation
Answer: C. Weigh the client each morning after voiding
Rationale:
A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.
B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.
C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.
D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.
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