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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","D","F"]

Explanation

Choice A Reason: Slow even breathing is not a sign of Cushing's Triad, which is a late indicator of increased intracranial pressure (ICP). The breathing pattern may be altered due to brainstem compression, but not necessarily slow or even.

Choice B Reason: This is a correct answer because bradycardia and bounding pulse are part of Cushing's Triad, which reflects an increased vagal tone and decreased cardiac output due to increased ICP.

Choice C Reason: Systolic hypotension with a narrowing pulse pressure is not a sign of Cushing's Triad, which involves an increased systolic blood pressure and a widened pulse pressure due to increased ICP. Hypotension may occur due to shock or hemorrhage, but not as a result of increased ICP.

Choice D Reason: This is a correct answer because irregular respirations are part of Cushing's Triad, which reflects impaired respiratory control due to brainstem compression from increased ICP. The respirations may be Cheyne-Stokes, central neurogenic hyperventilation, apneustic, or ataxic.

Choice E Reason: Tachycardia and bounding pulse are not signs of Cushing's Triad, which involves bradycardia and bounding pulse due to increased ICP. Tachycardia may occur due to pain, anxiety, fever, or hypoxia, but not as a result of increased ICP.

Choice F Reason: This is a correct answer because systolic hypertension with a widening pulse pressure are part of Cushing's Triad, which reflects an increased cerebral perfusion pressure due to increased ICP. The diastolic blood pressure remains stable or decreases, resulting in a widened pulse pressure.

A. 9 B. 11 C. 15 D. 13

Correct Answer is A

Explanation

Choice A Reason: This is correct because the patient's Glasgow Coma Scale score is 9. The Glasgow Coma Scale is a tool that assesses the level of consciousness of a patient with a head injury by measuring three parameters: eye opening, verbal response, and motor response. The patient's eye opening score is 3 (opens eyes to verbal command), verbal response score is 4 (confused speech), and motor response score is 2 (withdraws from pain). The total score is the sum of these three scores, which is 9.

Choice B Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 11. To get a score of 11, the patient would need to have a higher motor response score, such as 4 (withdraws to touch) or 5 (localizes to pain).

Choice C Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 15. To get a score of 15, the patient would need to have the highest scores for all three parameters, such as 4 (opens eyes spontaneously), 5 (oriented speech), and 6 (obeys commands).

Choice D Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 13. To get a score of 13, the patient would need to have a higher verbal response score, such as 5 (oriented speech).

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following manifestations will the nurse expect to find? (Select all that apply.)

Correct Answer is ["B","D","F"]

Explanation

A patient with a head injury opens his eyes to verbal stimulation, shouts out when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?

Correct Answer is A

Explanation

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

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?

A client arrives to the emergency department after losing consciousness during a soccer game. Which of the following actions should the nurse take first?

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

A client with red scaling papules on his elbows, knees, lower back, and scalp arrives to the clinic. Which of the following questions will the nurse include in her assessment?

A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?