Answer: Show Pad the client's wrists before applying the restraints. Rationale: The use of restraints without padding can abrade the client's skin, resulting in client injury. The client's circulation, ROM, vital signs, and overall status should be evaluated every 15 minutes, not 8 hours. The restraints should be removed at least every 2 hours to reposition and assess toileting/hygiene needs, not every 4 hours. The restrains should be secured to a part of the bedframe, not the side rails. Recommended textbook solutions
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Jensen Terms in this set (37)As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?
The client and the examiner see the examiner's finger at the same time. Explanation: The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation. A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following? Consensual response Explanation: When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light on one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict. A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity? Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time Explanation: Near vision is tested with a Jaeger card, Snellen card, or comparable card), held 14 inches from the face. Have the client cover one eye with an opaque card before reading from top to bottom. Sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner is a test for gross peripheral vision. If the client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart and record the smallest line the client can read is the test for distant acuity. A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card? Instruct the client hold the chart 14 inches from the eyes Explanation: To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arms length is an arbitrary length depending on the size of the client and is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client. A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform? Assess the nasolacrimal sac Explanation: Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength, such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve. A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears. A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? Consensual response Explanation: When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light in one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict. A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next? Arrange for worker to be promptly assessed by an eye specialist. Explanation: The nurse should refer the client to an eye doctor immediately if a foreign body cannot be removed with gentle washing. Optometrists are specialists in primary vision care and do not normally treat eye trauma. Irrigation with hydrogen peroxide or attempted removal using instruments would be contraindicated and potentially dangerous. The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope in the right hand for the right eye and in the left hand for the left eye An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? macular degeneration Explanation: Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender. Cataracts are characterized by cloudiness of the eye lenses. Glaucoma is an increase in intraocular pressure that places pressure on eye structures and affecting vision. A detached retina is the sudden loss of vision in one eye. This health problem may be precipitated by the appearance of blind spots. When testing the near reaction, an expected finding includes which of the following? Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze. On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Perform both the distant and near visual acuity tests Explanation: The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination. A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? Corrective lenses Explanation: Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition. A nurse is preparing to assess the distal visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? Ask the client to remove the glasses before testing. Explanation: When testing distant visual acuity, the nurse should have the client remove the reading glasses, because they blur distant vision. The client would wear his or her glasses during the test if they were not reading glasses. The nurse would still test the client's distant visual acuity. The E chart would be appropriate if the client could not read or has a handicap that prevents verbal communication. A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client? Brain tumor Explanation: Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor. Vitamin A deficiency is a cause of night blindness. Allergies are usually indicated by burning or itching pain in the eye. Viral infection is usually indicated by redness or swelling of the eye. The functional reflex that allows the eyes to focus on near objects is termed accomodation Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens. A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? Consensual reaction Explanation: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object. A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumor and inflammation in the orbit. The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should position the client 609.6 cm (20 ft) away from the chart. Explanation: Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them. What is vital in maintaining vision and a healthy outlook for clients? Health Education Explanation: Nursing education is vital in maintaining vision and a healthy outlook for clients. Which vision acuity reading indicates blindness? 20/200 Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision. A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client? Presbyopia Explanation: Presbyopia, which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from the eyes to focus on the print. It is caused by decreased accommodation and is a common condition in clients over 45 years of age. With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. What is a characteristic symptom of Graves hyperthyroidism? Exophthalmos Explanation: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism. The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what? Conjunctiva Explanation: The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae). The border between the cornea and the sclera is the limbus. The lacrimal apparatus protects and lubricates the cornea and the conjunctiva by producing and draining tears. The eyelid is a loose fold of skin that covers and protects the eye. An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible glaucoma Explanation: A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma. A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis has a watery, mucoid discharge A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment? Blunt-force trauma often results in fracture of the orbit Explanation: High-velocity injuries are typically penetrating. Blunt-force trauma often results in fracture of the orbit. Optic atrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eye. When using hand gel to clean the hands, what must the nurse do before touching a client's eyes? Make sure the hands are completely dry Explanation: If using hand gel, the nurse should ensure that the hands are completely dry before touching the client's eye. The nurse does not have to rewash hands with soap and water. The nurse would not start by assessing visual acuity or color blindness. The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? Far, then near Explanation: When testing accommodation, the nurse would ask the client to focus on a distant object such as a finger or pencil and to remain focused on that object as the nurse moves it closer to the eyes. Which of the following assessment findings suggests a problem with the client's cranial nerves? A client's extraocular movements are asymmetrical and she complains of diplopia. Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology. A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action? Observing the eye's reaction when a light is shone into the opposite eye Explanation: The nurse assesses consensual response at the same time as direct response by shining a light obliquely into one eye and observing the pupillary reaction in the opposite eye. This does not involve a comparison between maximum and minimum pupil size, however. Neither eye is covered, and peripheral vision is not relevant to this assessment. Which technique by the nurse demonstrates proper use of the ophthalmoscope? Asks the client to fix the gaze upon an object and look straight ahead Explanation: After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula. While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's esotropia Explanation: Esotropia is an inward turn of the eye. When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction? up Explanation: The correct technique to use when examining a client's sclera and conjunctiva during an eye examination is to instruct the client to look up. Having the client look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination. A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent macular degeneration Explanation: Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision. The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding? Eye turning inward Explanation: Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to an oscillating or a shaking movement of the eye. The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart? Does not speak English Explanation: The Snellen E chart can be used for clients who do not speak English. This chart is not used for clients being treated for glaucoma, color blindness, or recovering from cataract surgery. 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engineering When fluid in a long pipe starts up from rest at a uniform acceleration a, the initial flow is laminar. The flow undergoes transition to turbulence at a time t* which depends, to first approximation, only upon a, ρ, and μ. Experiments by P. J. Lefebvre, on water at 20°C starting from rest with 1-g acceleration in a 3-cm-diameter pipe, showed transition at t* = 1.02 s. Use this data to estimate (a) the transition time and (b) the transition Reynolds number $$ Re_D $$ for water flow accelerating at 35 m/s² in a 5-cm-diameter pipe. Verified answer physics An astronomer is looking at the spectrum of a galaxy and finds that it has an oxygen spectral line of 525 nm, while the laboratory value is measured at 513 nm. Calculate how fast the galaxy would be moving relative to Earth. Explain whether the galaxy is moving toward or away from Earth and how you know. Verified answer
health Apply the language of the cardiovascular system. Select the best answer to complete each statement. LO 10.7, 10.8, 10.D The combining form thromb/o- means a. clot b. lump c. plug d. vein Verified answer Recommended textbook solutionsPharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 388 solutions
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Medical Language Accelerated2nd EditionAndrew Cavanagh, Steven Jones 568 solutions What action should the nurse take when testing a client's near vision quizlet?Explanation: To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision.
Which of the following action should a nurse take to assess a client?The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.
Which of the following actions should the nurse perform first?Assessment is the first step of the nursing process and takes priority over all other steps. It is essential that you complete the assessment phase of the nursing process before you implement nursing activities.
What test should the nurse use to test a client's gross hearing acuity?Standardized Testing: The Rinne test and the Weber test for the assessment of hearing can be done using a tuning fork.
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What action should the nurse take when testing a clients near vision quizlet?
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