The nurse is performing a physical assessment on a 3-year-old child. The parents state that the child excessively rubs the eyes and often tilts the head to one side
What visual impairment should the nurse suspect?
a. Strabismus
b. Astigmatism
c. Hyperopia, or farsightedness
d. Myopia, or nearsightedness
ANS: D
Clinical manifestations of myopia include excessive eye rubbing, head tilting, difficulty reading, headaches, and dizziness. Strabismus, astigmatism, and hyperopia have other clinical manifestations.
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A nurse is instructing a client regarding medications and substances contraindicated for the client with heart failure. Which of the following would not be contraindicated?
1. Alcohol 2. Furosemide 3. Metformin 4. Pioglitazone
When you have to turn, reposition, or transfer a person, you must:
a. Use a transfer belt b. Use a lift sheet c. Use a mechanical lift d. Use your body correctly
A client with GAD states, "I have learned that the best thing I can do is to forget my worries." How would the nurse evaluate this statement?
a. The client is developing insight. b. The client's coping skills have improved. c. The client needs encouragement to verbalize feelings. d. The client's treatment has been successful.
The goal identified in the nursing care plan is that "the client will be able to wash himself after a 4-week therapy session." When should the nurse evaluate the client's progress toward this goal?
a. On an ongoing basis b. At the end of four weeks c. Weekly d. Before the client's discharge