During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

Presbyopia

Cataracts

Tropia

Myopia

Answer and Explanation

The Correct Answer is A

A) Presbyopia: Presbyopia is an age-related condition where the lens of the eye loses elasticity, making it harder to focus on close objects. This condition typically begins to affect individuals around the age of 40, causing them to hold reading materials farther away to see them clearly. The client's complaint aligns perfectly with this common symptom of presbyopia.

B) Cataracts: Cataracts involve the clouding of the eye's lens, leading to overall blurry vision, glare, and difficulty with night vision. Although cataracts can interfere with reading, they do not specifically cause the need to hold reading materials farther away, which is more indicative of presbyopia.

C) Tropia: Tropia is a type of strabismus where one eye deviates from normal alignment, leading to symptoms like double vision or eye strain. This condition affects how the eyes coordinate but does not typically cause the specific symptom of needing to hold reading materials farther away.

D) Myopia: Myopia, or nearsightedness, results in clear vision for close objects but blurry vision for distant objects. The client's issue of needing to hold reading materials farther away to see clearly is inconsistent with myopia, which would cause difficulty with distant vision instead.

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Correct Answer is C

Explanation

A) Intercostal spaces:

Assessing intercostal spaces typically involves palpating or inspecting the area between the ribs to check for abnormalities such as retractions or tenderness, usually conducted with the client sitting or standing.

B) Lymph nodes:

Palpation of lymph nodes, such as in the cervical region, involves using fingertips to gently feel for enlarged or tender nodes. This examination focuses on areas like the neck, underarms, and groin.

C) Skin Turgor:

The image depicts a nurse pinching the skin, likely on the chest or forearm, which is a common method to assess skin turgor. Skin turgor evaluation helps determine hydration status; if the skin remains tented and returns slowly to its original position, it indicates dehydration.

D) Carotid Pulse:

Assessing the carotid pulse involves palpating the carotid artery along the side of the neck to evaluate the strength and rhythm of the pulse. This is typically done using the pads of the fingers, not by pinching the skin.

A. "I do not eat salty foods and snacks B. "My rings are not fitting on my fingers like they usually do" C. "I exercise about 20 minutes a day by walking" D. "High blood pressure is present in my mother & grandmother"

Correct Answer is B

Explanation

A) "I do not eat salty foods and snacks": This statement indicates the client's dietary habits and, while it can impact overall health, it does not necessarily require immediate validation unless there is reason to doubt its accuracy or it is related to a specific health concern being addressed.

B) "My rings are not fitting on my fingers like they usually do": This statement suggests a change in the client's physical condition, likely indicating fluid retention or edema. This symptom requires validation as it could signify an underlying issue such as heart failure, kidney problems, or other medical conditions that need prompt attention.

C) "I exercise about 20 minutes a day by walking": This statement reflects the client's physical activity routine. While it's important for assessing overall health and fitness, it does not demand immediate validation unless related to a specific health issue.

D) "High blood pressure is present in my mother & grandmother": This statement provides valuable family history information, which is important for assessing genetic risk factors. However, it does not require urgent validation compared to physical changes indicating potential health problems.

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During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

Nursing Test Bank

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