on inspection which client does the nurse suspect of having a visual impairment

ATI RN

Multi Dimensional Care | Final Exam

1. On inspection, which client does the nurse suspect of having a visual impairment?

A. The client whose sclera is white
B. The client who has an intact blink reflex
C. The client who is tilting their head
D. The client with equal pupils

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

2. Which among the following is NOT the cause of pressure ulcers?

A. Immobility
B. Poor nutrition
C. Moisture
D. Adequate perfusion

Correct answer: D

Rationale:

3. A man has been admitted to the hospital unit with a medical diagnosis of COPD. He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing?

A. Prone position
B. Sim's position
C. Lateral position
D. Fowler's position

Correct answer: D

Rationale:

4. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

A. Encouraging bedrest
B. Applying antiembolism stockings
C. Tell the client to take anticoagulants
D. Teaching about smoking cessation

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.