A nurse is preparing to assess a 4-year-old child's visual acuity. Which of the following actions should the nurse plan to take?
Assess both eyes together first, then each eye separately.
Position the child 4.6 meters (15 feet) from the chart.
Test the child without glasses before testing with glasses.
Use a tumbling E chart for the assessment.
The Correct Answer is D
A. Visual acuity should be assessed for each eye separately first, then both eyes together to detect any differences between the eyes.
B. The nurse should position the child 3 meters (10 feet) from the chart and ask the child to point in the direction of the open end of each letter.
C. If the child wears glasses, they should be tested with and without their glasses to assess visual acuity accurately.
D. A tumbling E chart, where the child identifies the direction of the E (up, down, left, or right), is commonly used for assessing visual acuity in young children who may not yet know letters.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. Offering a prize for not crying may inadvertently reinforce crying as an expectation.
B. This statement is not accurate because the medicine might not fix the problem or make the child feel better immediately.
C. Assuring the child that they will only feel a little stick is not honest because the injection might hurt more than a little stick, and lying to the child can damage the trust between the nurse and the child.
D. Allowing the child to choose the injection site allows the child to have some control and autonomy over the situation, which can reduce anxiety and fear.
Correct Answer is D
Explanation
A) Abrasions on the knees could result from normal childhood activities and may not indicate physical abuse.
B) Front deciduous teeth missing could be due to normal tooth loss.
C) Weight in the 45th percentile is within a normal range and does not necessarily indicate physical abuse.
D) Bruising around the wrists is concerning for physical abuse, especially in a pattern consistent with restraining or gripping.
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