Which nutritional data obtained from a client needs MOST validation by a nurse?
"I do not eat salty foods and snacks
"My rings are not fitting on my fingers like they usually do"
"I exercise about 20 minutes a day by walking"
"High blood pressure is present in my mother & grandmother"
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Eye turning inward:
Esotropia is a condition where one or both eyes turn inward, leading to misalignment. This inward turning can cause double vision, depth perception issues, and sometimes amblyopia (lazy eye) if not treated early. This is the primary characteristic that defines esotropia.
B) Eye malalignment:
While eye malalignment is a general term that can describe conditions like esotropia, exotropia, or hypertropia, it does not specify the direction of the misalignment. Esotropia specifically refers to inward turning of the eye, which is a more precise description of the condition.
C) Eye oscillating:
Eye oscillation refers to nystagmus, which is a condition characterized by repetitive, uncontrolled movements of the eyes, often resulting in reduced vision. Nystagmus is not related to esotropia, which involves inward turning rather than oscillation.
D) Eye turning outward:
Eye turning outward is known as exotropia, which is the opposite of esotropia. Exotropia involves the eyes turning away from the nose, whereas esotropia involves the eyes turning towards the nose. These are distinct conditions with different clinical presentations.
Correct Answer is C
Explanation
A) Loss of vision in one eye:
Loss of vision in one eye is not related to hyperopia (farsightedness). This condition could be due to various other causes such as retinal detachment, optic neuropathy, or trauma, but it does not describe the refractive error associated with hyperopia.
B) Clear vision of nearby objects, but difficulty seeing distant objects:
This description pertains to myopia (nearsightedness), where individuals can see nearby objects clearly but struggle with seeing distant objects. Hyperopia is the opposite, involving difficulty with near vision rather than distance vision.
C) Clear vision of distant objects, but difficulty seeing nearby objects:
Hyperopia, or farsightedness, is characterized by clear vision of distant objects while nearby objects appear blurry. This occurs because the eye's light focuses behind the retina rather than directly on it, making close-up tasks like reading challenging.
D) Blurry vision of both distant and nearby objects:
Blurry vision of both distant and nearby objects is not specific to hyperopia and may indicate other eye conditions such as astigmatism or severe refractive errors that affect overall visual acuity, rather than the specific issue of near vision seen in hyperopia.
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