A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

20 represents the distance you are placed from the chart and 40 represents the distance a normal eye read the chart.

20 represents the distance a normal eye can read and 40 represents the distance your eye read the chart.

20 represents the distance you are placed from the chart and 40 represents the distance your eye read the chart.

40 represents the distance you are placed from the chart and 20 represents the distance a normal eye read the chart.

Answer and Explanation

The Correct Answer is A

A. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye reads the chart:

This is correct. The first number (20) represents the distance in feet the patient is from the Snellen chart. The second number (40) indicates the distance at which a person with normal vision can read the same line. Therefore, 20/40 means that what the patient can read at 20 feet, a person with normal vision can read at 40 feet.

B. 20 represents the distance a normal eye can read and 40 represents the distance your eye reads the chart:

This is incorrect. The first number should represent the distance the patient is from the chart, not the normal eye's reading distance.

C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye reads the chart:

This is incorrect. While the first number is correct (the distance from the chart), the second number should represent the distance a person with normal vision can read the same line, not the patient's distance.

D. 40 represents the distance you are placed from the chart and 20 represents the distance a normal eye reads the chart:

This is incorrect. The standard for visual acuity measurements is that the first number represents the testing distance (usually 20 feet), and the second number represents the distance at which a normal eye can read the line.

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Correct Answer is C

Explanation

A. Acanthosis Nigricans:

Acanthosis nigricans is characterized by dark, velvety patches of skin, often found in body folds such as the neck, armpits, and groin. It does not present as the yellow discoloration seen in the photo.

B. Cyanosis:

Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. The image shows yellow discoloration, not the blue tint associated with cyanosis.

C. Jaundice:

Jaundice is indicated by a yellowish tint to the skin and sclera due to elevated bilirubin levels, commonly associated with liver dysfunction. The photo clearly shows this yellow discoloration, consistent with jaundice, often seen in chronic alcoholics with liver disease.

D. Carotenemia:

Carotenemia presents as a yellow-orange discoloration of the skin, especially on the palms and soles, due to high levels of carotene in the blood. It does not typically affect the sclera, which differentiates it from jaundice. The uniform yellowing of the skin and eyes in the photo aligns more with jaundice.

A. to prevent further dehydration B. to assist the client to feel more comfortable C. to observe the movement of the thyroid gland D. to promote the nurse-client relationship

Correct Answer is C

Explanation

A. To prevent further dehydration:

While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.

B. To assist the client to feel more comfortable:

Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.

C. To observe the movement of the thyroid gland:

Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.

D. To promote the nurse-client relationship:

Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.

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A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

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Naxlex Comprehensive Predictor Exams

A 75-year-old male who is a chronic alcoholic present to the medical office for his annual wellness visit. How would describe the findings found in photo?

Correct Answer is C

Explanation

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

Correct Answer is C

Explanation

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