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When performing the confrontation test to assess peripheral vision, what action should the nurse take?
- A. Asks the client to identify a small object brought into the visual field
- B. Has the client cover one eye while the nurse covers one eye and slowly advances a target midline between them
- C. Covers one eye, while the client covers the opposite eye, and brings a small object into the visual field
- D. Positions at eye level with the client, covers one eye, and has the client cover the opposite eye, then brings a small object into the visual field
Correct Answer: D
Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits. Choices A, B, and C are incorrect. Choice A pertains to testing color vision, which is not part of the confrontation test. Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test. Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.
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When preparing to assist the healthcare provider in examining a client's skin with the use of a Wood light, what action should the nurse perform?
- A. Darken the room
- B. Obtain informed consent from the client
- C. Obtain a scalpel and a slide for diagnostic evaluation
- D. Obtain medication to anesthetize the skin area before proceeding with the examination
Correct Answer: A
Rationale: When using a Wood light during a skin examination, the room should be darkened to enhance the visibility of fluorescence. The Wood light emits long-wavelength ultraviolet light, highlighting certain skin conditions. Darkening the room aids in better visualization. Obtaining informed consent is a crucial aspect of healthcare but not directly related to using a Wood light. Obtaining a scalpel and a slide is unnecessary for a noninvasive Wood light examination. Anesthetizing the skin area is not required as the procedure is painless and noninvasive.
A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?
- A. Normally heard in the lungs
- B. Hollow sounds heard over the trachea and larynx
- C. Rustling sounds heard over the peripheral lung fields
- D. Abnormal sounds that should not be heard in the lungs
Correct Answer: D
Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.
During a home visit, the LPN finds a client taking Amiodarone. Which statement by the client indicates an understanding of potential drug side effects?
- A. "It is normal if I have numbing or tingling in my feet."?
- B. "I need to make sure I wear sunblock when going outdoors."?
- C. "I need to take supplemental vitamin B12."?
- D. "I should avoid eating leafy vegetables."?
Correct Answer: B
Rationale: The correct answer is B. Amiodarone can cause increased photosensitivity, making it essential for the client to wear sunblock when exposed to sunlight. Choice A is incorrect because numbing or tingling in the feet is not a common side effect of Amiodarone. Choice C is unrelated as the drug does not typically require supplemental vitamin B12. Choice D is also incorrect as there is no need to avoid leafy vegetables specifically due to Amiodarone.
The LPN participates in a home visit for a client with Type 2 Diabetes who has been taking Metformin for 3 years. The client states that for the past 3 months, they have been trying a vegan diet and experiencing fatigue, confusion, and mood changes. What is a likely cause of the new symptoms?
- A. vitamin B12 deficiency
- B. chronic hypoglycemia
- C. vitamin D deficiency
- D. increased tolerance to Metformin
Correct Answer: A
Rationale: The correct answer is vitamin B12 deficiency. Long-term use of Metformin can lead to vitamin B12 deficiency, and a vegan diet is low in vitamin B12. Symptoms of vitamin B12 deficiency include anemia, fatigue, confusion, and mood changes. Chronic hypoglycemia is unlikely in a client with Type 2 Diabetes who has been taking Metformin as it typically causes hyperglycemia. Vitamin D deficiency usually presents with symptoms related to bones and muscles, not confusion and mood changes. Increased tolerance to Metformin does not explain the client's new symptoms, which are more indicative of a nutritional deficiency like vitamin B12.
A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?
- A. Placing a tape measure around the widest point of the lower leg
- B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point
- C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point
- D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point
Correct Answer: A
Rationale: To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option B), 2 inches above the ankle (Option C), or 2 inches below the patella (Option D) would not provide an accurate measurement of the calf circumference. Therefore, these options are incorrect choices.