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
Choice A rationale
Antiviral therapy is typically used to treat viral infections. However, meningitis is most commonly caused by bacteria. Therefore, antiviral therapy would not be the most effective treatment in this case.
Choice B rationale
Antibiotic therapy is the standard treatment for bacterial meningitis. The specific antibiotic or combination of antibiotics used depends on the type of bacteria causing the infection.
Therefore, after reviewing lab results that suggest meningitis, the nurse would anticipate the provider to prescribe antibiotic therapy.
Choice C rationale
Antiemetics are medications that help prevent and treat nausea and vomiting, which can be symptoms of meningitis, but they do not treat the underlying cause of meningitis.
Choice D rationale
Analgesics are used to relieve pain. While they might be used to manage the headache often associated with meningitis, they would not treat the infection itself.
Correct Answer is A
Explanation
Choice A rationale
Speaking slowly and clearly using yes/no questions one at a time can help facilitate communication with a client diagnosed with aphasia.
Choice B rationale
Asking a family member if they know what the client wants may not always be effective, as the client may have difficulty expressing their needs even to family members.
Choice C rationale
Repeating the same question multiple times may not be effective and could potentially frustrate the client.
Choice D rationale
Putting a cell phone in their right hand to text their questions assumes that the client has the ability to text, which may not be the case for all clients diagnosed with aphasia.
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