28) The nurse is assessing a school-age child's visual activity using a Snellen chart. The child cannot identify several letters and number on the chart at a distance greater than 20 feet. Which action should the nurse implement? A. Listen to the child's articulation of common words. B. Use artificial tears in the clients' eyes and repeat the test. C. Report the findings to the healthcare provider. D. Ask the child about the ability to read words clearly.
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- A nurse is assessing a patient’s eyes for accommodation.What actions would the nurse perform during this test? Selectall that apply.a. Bring a penlight from the side of the patient’s face andbriefly shine the light on the pupil.b. Hold a forefinger, a pencil, or other straight object about 10to 15 cm (4′′ to 6′′) from the bridge of the patient’s nose.c. Hold a finger about 6′′ to 8′′ from the bridge of thepatient’s nose.d. Darken the room.e. Ask the patient to look straight ahead.f. Ask the patient to first look at a close object, then at adistant object, then back to the close object.What consideration should the nurse keep in mind regardingthe use of side rails for a confused patient?a. They prevent confused patients from wandering.b. A history of a previous fall from a bed with raised siderails is insignificant.c. Alternative measures are ineffective to prevent wandering.d. A person of small stature is at increased risk for injuryfrom entrapment.The nurse is educating a postoperative patient about their patient-controlled analgesia pump. Which instructions should the nurse include? Select all that apply. a. Inform the nurse about the pain level being experienced b. Push the button before the pain is unbearable c. Ask the family to push the button as needed d. Report the inability to void e. Report any nausea and vomiting
- A nurse is assessing a patient’s eyes for extraocular move-ments. Which action correctly describes a step the nurse would take when performing this test?a. Ask the patient to sit about 3 feet away facing the nurse.b. Keep a penlight about 1 foot from the patient’s face andmove it slowly through the cardinal positions.c. Move a penlight in a circular motion in front of thepatient’s eyes.d. Ask the patient to cover one eye with a hand or indexcard.The nurse is performing neurologic assessment on patient with an arsficial eye. How would the nurse confirm identification of the natural eye? 1 Only the natural eye would produce tears and lubrication. 2 The arcificial eye would have more natural movement. 3 The arsificial eye would respond siightly to a light stmulus. 4 Accommadation would only be present n the natural eye.What activities will the nurse tell the client to avoid after cataract surgery? (Select all that apply.) Sleeping for greater than 1 hour Lifting items greater than 10 pounds Blowing one's nose Bearing down when one defecates Urinating
- Minerva is given a propranolol (Inderal) 40 mg bid. What is the most important instruction the nurse should give to this client?a. Take this medication on an empty stomach, as food interferes with its absorption.b. Do not stop taking this medication abruptly; the dosage must be decreased gradually if it isdiscontinued.c. If the client experiences any disturbances in hearing, the client should notify the health care providerimmediately.d. The client may become very sleepy while taking this medication; do not drive.Is letter b the correct answer why or why not? Also explain why the other options are not the right answer (a,c and d)A nurse discovers that she made a medication error. Whatshould be the nurse’s first response?a. Record the error on the medication sheet.b. Notify the physician regarding course of action.c. Check the patient’s condition to note any possible effect ofthe error.d. Complete an incident report, explaining how the mistakewas made.A visiting nurse is performing a family assessment of ayoung couple caring for their newborn who was diagnosedwith cerebral palsy. The nurse notes that the mother’s hairand clothing are unkempt, the house is untidy, and themother states that she is “so busy with the baby that I don’thave time to do anything else.” What would be the priorityintervention for this family?a. Arrange to have the infant removed from the home.b. Inform other members of the family of the situation. c. Increase the number of visits by the visiting nurse.d. Notify the care provider and recommend respite care forthe mother.
- A nurse is diagnosing an 11-year-old 6th grade studentfollowing a physical assessment. The nurse notes that the student’s grades have dropped, she has difficulty complet-ing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen’s eye chartis 160/20. Which nursing diagnosis would be mostappropriate?a. Deficient Knowledge related to visual impairmentb. Ineffective Role Performance (Student) related to visualimpairmentc. Disturbed Body Image related to visual impairmentd. Delayed Growth and Development related to visualimpairmentAnswer the following? The Joint Commission issues guidelines regarding the use ofrestraints. In which case is a restraint properly used?a. The nurse positions a patient in a supine position prior toapplying wrist restraints.b. The nurse ensures that two fingers can be inserted betweenthe restraint and patient’s ankle.c. The nurse applies a cloth restraint to the left hand of apatient with an IV catheter in the right wrist.d. The nurse ties an elbow restraint to the raised side rail of apatient’s bed.1) The nurse has administered an opioid analgesic to a client. Which interventions should the nurse implement? Select all that applyA. Discuss with the physician starting the client on a stool softener.B. Teach the client about rating the pain on a numeric pain scale.C. Inform the client to rise quickly from a supine position.D. Tell the client to call for assistance when getting out of bed. 2). Mrs. Lee has been taking ibuprofen for the last 2 months. She has noticed both her knees are occasionally red and warm when she touches them. She has observed that besides her knee pain, the joints in her hands have been red with some swelling. The physician diagnoses Mrs. Lee with rheumatoid arthritis and gout. He starts her on allopurinol 100mg PO every day and celecoxib 100mg PO BID for pain. In teaching Mrs. Lee about her new medication regimen: You describe to Mrs. Lee how allopurinol will help in the management of her joint pain. What is your best explanation?A. “Allopurinol reduces the…