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 A

Explanation

A.Ensuring the client's heels are not touching the mattress: Pressure injuries, particularly on the heels, are common in clients who are immobile and on bed rest. Elevating the heels off the mattress helps to alleviate pressure and reduce the risk of developing pressure injuries in this area.

B.Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.

C.Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.

D, Reposition the client every 4 hr.

Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.

A. "You need to understand that you have very little time left." B. "I will contact your provider to discuss your options." C. "Enjoy the time you have and do the things you want to do." D. "Hospice care is the best thing for you at this time."

Correct Answer is B

Explanation

A. "You need to understand that you have very little time left":

This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.

B. "I will contact your provider to discuss your options":

This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan

C. "Enjoy the time you have and do the things you want to do":

This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.

D. "Hospice care is the best thing for you at this time":

While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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