A nurse is performing a focused assessment for a client's vision. What visual assessment is the nurse making when she extends her hand for the client to shake?

Depth perception

Peripheral vision

Color deficit

Double vision

Answer and Explanation

The Correct Answer is B

Choice A Reason: Depth perception is the ability to judge the distance and position of objects in three-dimensional space. Depth perception is assessed by asking the client to touch the tip of a pen or pencil held by the nurse, or by using a stereopsis test.

Choice B Reason: Peripheral vision is the ability to see objects and movements outside the direct line of vision. Peripheral vision is assessed by asking the client to shake the hand of the nurse, who stands at an angle to the client's side, or by using a confrontation test.

Choice C Reason: Color deficit is the inability to distinguish certain colors or shades of colors. Color deficit is assessed by asking the client to identify numbers or shapes on a color plate test, such as the Ishihara test.

Choice D Reason: Double vision is the perception of two images of a single object. Double vision is assessed by asking the client to cover one eye and look at an object, then switch eyes and compare the images, or by using a cover-uncover test.

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Free Nursing Study Resources

Correct Answer is ["2600"]

Explanation

The total fluid prescribed is 5,200 mL over 24 hours. We need to calculate how much fluid the client will receive in the first 8 hours.

Step-by-Step Calculation:

Step 1: Determine how much fluid is given in the first 8 hours. The rule is that half of the total fluid is administered in the first 8 hours.

Total fluid = 5,200 mL.
Fluid for the first 8 hours = Total fluid ÷ 2.

Write it out:
5,200 ÷ 2 = 2,600.

Result: 2,600 mL.

A. Notify child protective services B. Record the finding C. Notify the healthcare provider D. Interview the clients about the injury

Correct Answer is B

Explanation

Choice A Reason: Notifying child protective services is not the priority action, as it is not indicated by the skin irregularity. The skin irregularity is most likely a Mongolian spot, which is a benign, bluish-gray or purple patch of pigmentation that is common in infants of Asian, African, or Hispanic descent. It is not a sign of abuse or injury, but rather a normal variation of skin color.

Choice B Reason: This is the correct choice. Recording the finding is the priority action, as it documents the presence and location of the Mongolian spot and prevents confusion or misdiagnosis in the future. The Mongolian spot usually fades by age 2 to 4 years, but it may persist into adulthood.

Choice C Reason: Notifying the healthcare provider is not the priority action, as it is not necessary for the skin irregularity. The skin irregularity is not a cause for concern or intervention, but rather a normal variation of skin color.

Choice D Reason: Interviewing the clients about the injury is not the priority action, as it is not appropriate for the skin irregularity. The skin irregularity is not an injury, but rather a normal variation of skin color. Interviewing the clients about it may imply suspicion or accusation of abuse, which can damage the nurse-client relationship and trust.

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A nurse is performing a focused assessment for a client's vision. What visual assessment is the nurse making when she extends her hand for the client to shake?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to start an IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many milliliters of fluid will the client receive in the first 8 hours? Record your answer.

Correct Answer is ["2600"]

Explanation

Step-by-Step Calculation:

An Asian family arrives with their newborn for a well visit. When assessing the infant, the nurse observes the following skin irregularity. What is the nurse's priority action?

Correct Answer is B

Explanation

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?

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