Nokea
A school nurse assesses adolescents' visual acuity using a Snellen eye chart. Which explanation does the nurse provide to the student whose vision is 20/40 in both eyes?
- A. They see better than 50% of people.
- B. Double vision is present.
- C. Vision is less than normal.
- D. They have normal vision.
Correct Answer: C
Rationale: Normal vision is 20/20. The higher the denominator indicates increasingly worse vision; 20/40 vision indicates less than normal vision.
You may also like to solve these questions
A nurse and AP are caring for a patient who just returned from the operating room after a femoral-popliteal arterial bypass graft. The nurse is getting another admission. What activity can the nurse safely delegate to the AP?
- A. Determining if pedal pulses are present
- B. Evaluating the patient's pain
- C. Reinforcing the sterile dressing
- D. Ordering dressing supplies
Correct Answer: D
Rationale: The nurse can delegate noncomplex activities to the AP such as obtaining (dressing) supplies, bedmaking, bathing, I & O, toileting, and ambulation. The nurse must perform assessments, provide teaching, perform sterile procedures, and develop the care plan.
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?
- A. Jaundice
- B. Cyanosis
- C. Erythema
- D. Pallor
Correct Answer: A
Rationale: Jaundice refers to a yellowish skin color caused by liver, gallbladder, or pancreatic diseases. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.
A nurse in the neurology clinic is assessing a patient's eyes for extraocular movements. Which correctly describes the procedure for this test?
- A. Ask the patient to sit about 3 ft away, facing the nurse.
- B. Have the patient follow a penlight held 1 ft from their face slowly through the cardinal positions.
- C. Move a penlight in concentric circular motion in front of the patient's eyes.
- D. Ask the patient to cover one eye with a hand or index card.
Correct Answer: B
Rationale: The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 ft away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal positions of gaze-up and down, left and right, diagonally up and down to the left, diagonally up and down to the right. Option B most accurately describes this procedure.
A nurse is caring for a patient with exacerbation of COPD and pneumonia. When auscultating the lungs, coarse expiratory, low-pitched, and continuous sounds that clear with coughing are present. How will the nurse document this breath sound in the electronic health record?
- A. Rhonchi
- B. Bronchovesicular breath sounds
- C. Stridor
- D. Bronchial breath sounds
Correct Answer: A
Rationale: Rhonchi are abnormal low-pitched, continuous breath sounds auscultated during inspiration and occasionally expiration, indicating that air is passing through or around secretions. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Stridor is a harsh, loud, high-pitched sound auscultated on inspiration indicating narrowing of the upper airway or presence of a foreign body. Bronchial sounds are normal blowing, hollow sounds, auscultated over the larynx and trachea.
A nurse in the emergency department is using the Glasgow coma scale to assess a patient who was struck in the head and upper body with a baseball bat. Based on the information in the neurologic assessment, what numerical value will the nurse assign?
- A. 3
- B. 7
- C. 11
- D. 15
Correct Answer: B
Rationale: Eye opening to painful stimulus = 2 points, no speech = 1 point; and withdrawal to painful stimulus = 4 points, for a total score of 7. A score of 8 or less is associated with coma.