Author Question: As a component of a head to toe assessment, the nurse is preparing to assess convergence of the ... (Read 38 times)

jeatrice · **on:** Jul 23, 2018

As a component of a head to toe assessment, the nurse is preparing to assess convergence of the client's eyes. How should the nurse conduct this assessment?

A) Ask the client to follow her finger as she slowly moves it towards the client's nose.
B) Ask the client to look ahead while slowly bringing a pen light in from the side and to the client's pupil.
C) Ask the client to hold his head stationary while following a pencil from left to right.
D) Ask the client to read a Snellen chart from a distance of 20 feet.

Question 2

The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which of the following findings should the nurse document as an anomaly that may warrant follow-up?

A) The client states that a mole on his forehead has become larger in recent months.
B) Decreased skin turgor is evident when the skin is folded and then released.
C) Small, round, red spots are present on the client's forearms bilaterally.
D) There are some raised, brown areas on the backs of the client's hands.

orangecrush · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A
Eye convergence is assessed by holding your finger 6 to 8 from the patient's nose and asking the patient to follow it as it moves closer. A pen light is used to assess pupillary reaction. Visual acuity is assessed with the use of a Snellen chart. Following a pencil from side to side is a test for extraocular movements.

Answer to Question 2

Ans: A
Changes in the size or appearance of a mole always require further assessment and follow-up due to their association with skin cancer. Decreased skin turgor is an expected finding in older adults, as are diffuse red spots (cherry angioma) and raised, dark areas (senile lentigines).