The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Perform the confrontation test.

Ask the patient to read the print on a handheld Jaeger card.

Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

Use the Snellen chart positioned 20 feet away from the patient.

Answer and Explanation

The Correct Answer is D

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

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Correct Answer is A

Explanation

A. Indicates turbulent blood flow through a valve:

This statement is correct. A heart murmur is an abnormal sound during the heartbeat cycle, often indicating turbulent blood flow through a valve. Murmurs can result from various factors such as valve disorders, structural abnormalities, or other heart conditions.

B. Is an extra sound due to blood entering an inflexible chamber:

This statement is not accurate. Heart murmurs are primarily associated with turbulent blood flow rather than an extra sound related to an inflexible chamber.

C. Means that there is some inflammation around the heart:

This statement is incorrect. Heart murmurs are not specifically related to inflammation around the heart. They are primarily caused by issues with blood flow through the heart valves.

D. Is a high-pitched sound due to a narrow valve:

This statement is a bit oversimplified. While murmurs can sometimes be associated with narrow valves (stenosis), they can also result from various other valve abnormalities or conditions, and not all murmurs are high-pitched. The pitch and characteristics of a murmur can provide clues about its cause, but they are not the sole indicators.

A. Increased temperature B. Increase hematocrit C. Blood pressure 180/100 D. Respiratory rate 32 E. Heart rate 120bpm

Correct Answer is ["C","D"]

Explanation

A. Increased temperature: Fluid overload typically doesn't cause an increased temperature. Infections or other inflammatory processes are more likely causes of elevated body temperature.

B. Increased hematocrit: Fluid overload usually results in dilution of blood components, leading to a decreased hematocrit (lower concentration of red blood cells in the blood). An increased hematocrit is not a typical finding in fluid overload.

C. Blood pressure 180/100: Elevated blood pressure can be associated with fluid overload, especially if the overload is chronic. This is a correct assessment finding that requires intervention and monitoring.

D. Respiratory rate 32: An increased respiratory rate can be a sign of respiratory distress, which may occur in severe cases of fluid overload, especially if it leads to pulmonary edema. This is a correct assessment finding that requires intervention and further evaluation.

E. Heart rate 120 bpm: An increased heart rate can be a compensatory mechanism in response to fluid overload, especially if the heart is trying to maintain cardiac output. However, this heart rate alone is not specific enough to confirm fluid overload. Other signs and symptoms, such as edema, increased blood pressure, and respiratory distress, are more indicative of fluid overload.

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The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

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Naxlex Comprehensive Predictor Exams

A client was recently diagnosed with a heart murmur and is asking the nurse for more information. The nurse will educate the client that a heart murmur:

Correct Answer is A

Explanation

The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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