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 C
Explanation
A. Four-point alternating gait:
This gait involves a more natural and stable walking pattern. However, it requires weight-bearing on both legs, which may not be suitable for a client who can only bear weight on one leg.
B. Swing-through gait:
The swing-through gait is typically used by clients with bilateral lower extremity weakness. It involves swinging both legs through while supporting weight on the crutches. This gait is not suitable for a client who can only bear weight on one leg.
C. Three-point gait:
This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client uses crutches and swings or hops the non-weight-bearing leg forward, landing on the good leg. This gait provides stability and reduces weight-bearing on the affected leg.
D. Two-point alternating gait:
In a two-point alternating gait, the client advances the crutch and the opposite foot simultaneously. This gait is more energy-efficient than the four-point gait but requires weight-bearing on both legs. It is not suitable for a client who can only bear weight on one leg.
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