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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "Increase intake of vitamin B12":

Vitamin B12 is important for various bodily functions, including the health of nerves and red blood cells, but it is not directly associated with osteoporosis prevention. Calcium and vitamin D are more critical nutrients for bone health.

B. "Walk for 30 minutes three to five times each week":

Weight-bearing exercises, such as walking, are beneficial for preventing osteoporosis. Weight-bearing activities stimulate bone formation and help maintain bone density. Regular walking for 30 minutes, three to five times per week, can contribute to overall bone health and reduce the risk of osteoporosis.

C. "Perform water aerobics three times each week":

While water aerobics is a beneficial exercise for cardiovascular health and joint flexibility, it is not as effective as weight-bearing exercises for preventing osteoporosis. Weight-bearing activities put stress on bones, promoting bone density.

D. "Maintain a lean body mass":

Maintaining a healthy body weight and lean body mass is important for overall health, but it is not a direct preventive measure for osteoporosis. Weight-bearing exercises and adequate intake of calcium and vitamin D are more specific recommendations for preventing osteoporosis.

A. Use trochanter rolls beside the client's legs. B. Logroll the client every 4 hr. C. Place the client's arms at their side when turning them. D. Cross the client's ankles when lying supine.

Correct Answer is A

Explanation

A. Use trochanter rolls beside the client's legs:

Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.

B. Logroll the client every 4 hr:

Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.

C. Place the client's arms at their side when turning them:

Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.

D. Cross the client's ankles when lying supine:

Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.

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A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

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Correct Answer is A

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