The nurse is obtaining a history on a client stating the inability to read the newspaper and even seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?
A) Assess if the pupils are equal and reactive to light.
B) Assess vision on the Snellen chart.
C) Assess peripheral vision.
D) Assess color vision.
C
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The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula. If the macula is damaged, the client will only have the ability to see movement and gross objects in the peripheral fields. Assessing the peripheral vision will add essential information. The other visual tests are not as important at this time.
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A person with a cerebellar lesion will have difficulty with
a. breathing. c. memory. b. equilibrium. d. speech.
Which grade for muscle strength is documented for a patient with active motion against full resistance?
1) + 2 2) + 3 3) + 4 4) + 5
Immediately prior to placing the client on a gurney for surgery, the nurse asks the client to remove the partial plate dentures. The client becomes upset and states, "No one can see me without my teeth. I am so embarrassed by the way I look without them." What is the nurse's best response to the client?
A. "I realize this is hard for you to do. I will ask the nurse in surgery to remove them for you after you go to sleep." B. "Why don't you take them out and drape this washcloth over your face so no one can see you without your teeth?" C. "Leaving your teeth in during surgery may cause injury to you or your teeth. Here is the cup for your dentures. Take them out right before surgery and then you can place them back in your mouth as soon as you wake up." D. "This is just something you have to put up with when you have surgery. No one knows you here so it won't be that embarrassing."