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. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?

A. Remove the cast to decrease pressure
B. Raise the arm above the level of the heart
C. Apply heat to the affected hand
D. Encourage range of motion

Correct answer: B

Rationale:

3. What are signs of hearing loss? (Select all that apply)

A. Presence of cerumen
B. Presence of cerumen
C. Tinnitus
D. Frequent asking of others to repeat statements

Correct answer: C

Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.

4. Which finding is not typically associated with inflammation in a client?

A. Pain
B. Heat
C. Polyuria
D. Erythema

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.