A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Eyelashes that curl slightly outward.
Eyelids that blink involuntarily 30 to 35 times per minute
Corneas with an opaque appearance
Pupils that are 8 to 9 mm in diameter
The Correct Answer is A
A. Eyelashes that curl slightly outward:
This is the correct answer. The direction and curl of eyelashes vary among individuals, but eyelashes that curl slightly outward are a normal and expected finding. This characteristic does not typically indicate any pathology or abnormality.
B. Eyelids that blink involuntarily 30 to 35 times per minute:
The normal range for involuntary blinking is approximately 15 to 20 times per minute. A rate of 30 to 35 blinks per minute may suggest increased nervousness or anxiety and is not within the expected normal range.
C. Corneas with an opaque appearance:
Normal corneas should have a clear and transparent appearance. Opacity of the cornea can be indicative of various eye conditions, such as corneal edema or scarring, and is not an expected finding in a healthy eye.
D. Pupils that are 8 to 9 mm in diameter:
The normal range for pupil size is approximately 2 to 6 mm in diameter. Pupils that are 8 to 9 mm in diameter may indicate abnormal dilation (mydriasis) and can be associated with conditions such as drug toxicity or neurological issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assault:
Assault occurs when one person intentionally threatens or causes another person to fear that they will be touched without their consent. In this situation, the nurse is threatening to administer medication by injection (an unwanted touch) as a consequence for not swallowing pills.
B. Invasion of privacy:
Invasion of privacy involves the unauthorized intrusion into an individual's personal matters. The nurse's statement does not relate to invading the client's privacy; it involves a threat related to the administration of medication.
C. Defamation:
Defamation involves making false statements that harm the reputation of another person. The nurse's statement is not making false statements about the client but rather threatening a specific action if a behavior is not followed.
D. Battery:
Battery occurs when there is intentional physical contact with another person without their consent. While the nurse's statement involves the administration of medication, the threat itself is considered assault. If the threat is carried out, and the medication is administered against the client's will, it would then be considered battery.
Correct Answer is A
Explanation
A. "It's nice having other people cook for me.":
This statement suggests adaptation to the new situational role. The client expresses a positive view of receiving help and support in daily activities, indicating a level of acceptance and adjustment to the changed living situation.
B. "I've never been the kind of person to ask others for help.":
This statement suggests a reluctance to seek help, and it may indicate a struggle with the new situational role. Adaptation often involves a willingness to accept assistance and support from others when needed.
C. "I'm looking forward to being able to be independent again.":
This statement indicates a positive attitude toward regaining independence, but it may not necessarily indicate full adaptation to the new situational role. The client is expressing a future orientation, and the actual adaptation will be evident when independence is achieved.
D. "I really don't know what I'm supposed to do all day.":
This statement suggests confusion or uncertainty about the daily routine, which may indicate a lack of adjustment to the new living situation. Adaptation involves a sense of understanding and comfort with one's roles and activities.
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