A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again.
d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.
ANS: D
If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity.
You might also like to view...
During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas?
a. "My stomach hurts. Hurts, spurts, burts." b. "Kiss, wood, reading, ducks, onto, maybe." c. "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom." d. "I wash my hands, wash them, wash them. I usually go to the sink and wash my hands."
Parents of a child with ADHD tell the nurse, "We try to teach our child how to behave, but it doesn't help. We feel as though we are terrible parents.". Select the nurse's most helpful response
a. Refer the parents for pastoral counseling. b. Discuss how traumatic life events precipitate ADHD. c. Explain the correlation between ADHD and parental conflict. d. Provide information about the relationship between ADHD and biochemical abnormalities.
The student nurse is starting the first clinical shift in a new facility and assesses the nurses working on the unit to identify a possible mentor. Which nurse would be the best choice for a mentor?
a. The friendliest, most outgoing nurse on the shift b. The new graduate who remembers what it is like to be a student c. The nurse others come to when they are unsure of how to proceed d. The nurse who is the most outspoken during change of shift report
The transmission of tetanus to humans is when a skin wound comes in contact with:
a. rusty metals such as a rusted nail b. soil contaminated with animal feces c. the bite of an insect carrying the tetanus organisms d. the saliva of an infected dog