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","C","D"]

Explanation

A. Cholesterol level:

While hyperlipidemia (elevated cholesterol levels) is associated with cardiovascular disease, it is not a direct factor affecting wound healing. Cholesterol levels primarily impact vascular health and are not directly related to the cellular and tissue processes involved in wound repair.

B. Prealbumin level:

Prealbumin is a protein that reflects recent dietary intake and nutritional status. Low prealbumin levels can indicate malnutrition, which is associated with delayed wound healing. Adequate protein intake is crucial for tissue repair and wound healing.

C. History of malnutrition:

Malnutrition is a significant risk factor for delayed wound healing. Adequate nutrition is essential for the body to carry out the processes involved in wound healing, including cell proliferation, collagen synthesis, and immune function.

D. History of diabetes mellitus:

Diabetes mellitus can impair wound healing due to factors such as reduced blood flow, impaired immune response, and neuropathy. Elevated blood sugar levels in diabetes can interfere with the normal healing processes, leading to delayed wound healing.

A. Administer the client's medications one at a time. B. Encourage the client to use a straw to take the medications. C. Give the client's medications between meals. D. Assist the client into semi-Fowler's position.

Correct Answer is A

Explanation

A. Administer the client's medications one at a time:

This is the correct action. Administering medications one at a time allows the nurse to monitor the client's ability to swallow each medication safely. It minimizes the risk of aspiration and ensures that each medication is swallowed effectively.

B. Encourage the client to use a straw to take the medications:

Using a straw may not be recommended for clients with dysphagia, as it can alter the normal swallowing process and increase the risk of aspiration. The focus should be on safe administration of medications without compromising the client's ability to swallow.

C. Give the client's medications between meals:

The timing of medication administration is important, but the priority is the safe administration of medications, especially for clients with dysphagia. Administering medications between meals may not directly address the safety concerns related to swallowing.

D. Assist the client into semi-Fowler's position:

While positioning is important, especially for clients with dysphagia, the administration of medications one at a time (Option A) takes precedence in ensuring the safety of the client's swallowing. Semi-Fowler's position may be beneficial, but it is not the primary action related to medication administration.

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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

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

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

Explanation

A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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