Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems

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4. Which assessment finding alerts the nurse to provide patient teaching about cataract development? 5. Assessment of a patients visual acuity reveals that the left eye can see at 20 feet what ... a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? 6. When assessing a patients consensual pupil response, the nurse should The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements. DIF: Cognitive Level: Apply (application) REF: 357 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination. DIF: Cognitive Level: Apply (application) REF: 364 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance ...................................................................CONTINUED............................................................... [Show More]

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