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 C

Explanation

A. The client tucks their chin when they swallow:
This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus
B. The client adjusts the head of their bed to 90°:
This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.
C. The client drinks their thickened juice with a straw:
This action indicates a potential problem. The use of a straw with thickened liquids is generally not recommended for clients with dysphagia. Thickened liquids are used to slow down the flow of the liquid and reduce the risk of aspiration. Drinking thickened juice through a straw may compromise the effectiveness of thickening and increase the risk of aspiration.
D. The client takes frequent breaks while eating:
This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.

A. Yogurt with fruit B. Pudding C. Cooked vegetables D. Bananas

Correct Answer is B

Explanation

A. Yogurt with fruit:

While yogurt with fruit is a soft and easily digestible option, it is not representative of a progression from a clear liquid diet to a full liquid diet. Yogurt is typically included in a full liquid diet, but the addition of fruit may introduce solid particles. The transition from clear to full liquids usually involves avoiding solid or textured foods.

B. Pudding:

Pudding is a suitable choice that aligns with the progression from a clear liquid diet to a full liquid diet. Pudding is a smooth and creamy food, making it appropriate for someone transitioning from clear liquids. It provides a source of calories and is easy to swallow, meeting the criteria for a full liquid diet.

C. Cooked vegetables:

Cooked vegetables are not part of a full liquid diet. While they are a healthy food choice, they are too textured for someone transitioning from a clear liquid diet. Full liquid diets focus on foods that are liquid at room temperature or become liquid when they reach body temperature.

D. Bananas:

Bananas are a soft and easily digestible fruit, but they are not typically included in a full liquid diet. The texture of bananas may be too thick for someone progressing from a clear liquid diet, and they are not considered a liquid or a food that becomes liquid at room temperature.

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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

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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