Author Question: A client in the clinic has been having severe headaches and some visual disturbances. The nurse ... (Read 49 times)

fasfsadfdsfa · **on:** Jul 22, 2018

A client in the clinic has been having severe headaches and some visual disturbances. The nurse performs an eye examination. Which of the following is true concerning the procedure for this assessment?

a. To evaluate the lower eyelids, the nurse uses a syringe with sterile water.
b. The client's lacrimal apparatus is best assessed by using a dull object to stimulate her normal reflex conditions.
c. Accommodation is tested by asking the client to comply with the nurse's requests.
d. The red reflex is assessed using the ophthalmoscope.

Question 2

Which of the following techniques is appropriate for the nurse to implement to obtain a clean-voided urine specimen?

a. Apply sterile gloves for the procedure.
b. Restrict fluids before the specimen collection.
c. Place the specimen in a clean urinalysis container.
d. Collect the specimen after the initial stream of urine has passed.

helenmarkerine · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
To visualize internal eye structures, the nurse uses an ophthalmoscope to focus on the red reflex.
To evaluate the lower eyelids, the nurse asks the client to open the eyes for inspection. A syringe and sterile water are not necessary for this assessment.
The lacrimal apparatus is best assessed by inspecting for edema and redness and palpating it gen-tly to detect tenderness. Normally it cannot be felt.
Accommodation is tested by asking the client to gaze at a distant object and then at a test object held by the nurse approximately 10 cm from the client's nose. The pupils normally converge and accommodate by constricting when looking at close objects.

Answer to Question 2

D

Feedback
A Nonsterile gloves are adequate in this instance.
B Fluids are encouraged so the patient will be more likely to be able to void.
C The specimen should be collected in a sterile container and then placed into a plastic specimen bag.
D To collect a clean-voided specimen, the nurse should collect the specimen (30 to 60 mL) after the initial stream of urine has passed.