The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?
Document findings
Determine whether the patient can count fingers
Obtain a tumbling E chart to assess visual acuity
Complete an internal eye exam .
The Correct Answer is B
Choice B rationale
If a patient states that he cannot see the top of the Snellen chart, the nurse should determine whether the patient can count fingers. If the patient is unable to read the top line of the Snellen
chart at 6 meters, the nurse can reduce the distance to 3 meters from the Snellen chart. If the patient still cannot read the chart, the nurse can then determine whether the patient can count fingers.
Choice A rationale
While documenting findings is an important part of the nursing process, it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice C rationale
Obtaining a tumbling E chart to assess visual acuity could be considered if the patient is unable to read letters or numbers, but it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice D rationale
Completing an internal eye exam would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: = b. Prostaglandins
Choice A: Carbonic anhydrase inhibitors: These medications can be used for glaucoma, but they are not typically the first-line treatment due to potential side effects.
Choice B: Prostaglandins (Correct Answer) These are often the preferred initial medication for glaucoma because they are effective at lowering eye pressure, have minimal systemic side effects, and are typically used once daily.
Choice C: Alpha-agonists: These medications can be used as an adjunct to other glaucoma medications but are not usually the first choice due to potential side effects like dry mouth and fatigue.
Choice D: Beta-blockers: While once a common first-line treatment, beta-blockers have been largely replaced by prostaglandins due to potential side effects like slowed heart rate and worsened breathing problems.
Correct Answer is B
Explanation
Choice A rationale
Analgesics can be used to manage pain associated with Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice B rationale
This is the correct answer. Chewing on the affected side can actually exacerbate swallowing issues. Therefore, this statement indicates a need for further education.
Choice C rationale
Brushing teeth should not be affected by Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice D rationale
Applying a protective eye shield before going to bed is a recommended practice for patients with Bell’s palsy. This helps to protect the eye from injury and keep it moist, as Bell’s palsy can cause difficulty in blinking or closing the eye.
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