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A nurse is caring for a client in an assisted living facility who has vision problems.

Medical history

A 68-year-old woman with complaints of having trouble reading the paper, sewing, and even seeing the faces of her grandchildren up close.

Nurse's notes

The client was noted to have some loss of nearsightedness

Complete the sentence by using the list of options.The findings noted by the health care practitioner suggest that

the client may have presbyopia

the client's vision is normal for someone her age

the client has the beginning stages of cataract formation the

client has increased intraocular or glaucoma

Answer and Explanation

The Correct Answer is A

A. Presbyopia is a common age-related condition that affects the ability to see close objects clearly, which aligns with the client's difficulty in reading, sewing, and seeing faces up close.

B. While some vision changes are expected with aging, the specific difficulties the client is experiencing suggest a more definitive condition rather than "normal" vision changes.

C. While cataracts can cause vision issues, the specific symptoms described (trouble reading and seeing objects up close) are more characteristic of presbyopia.

D. Glaucoma typically involves peripheral vision loss rather than difficulty with near vision, so this option is not supported by the findings.

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A. The client is restless. B. The client's pupils are dilated. C. The client reports a burning sensation. D. The client is grimacing

Correct Answer is C

Explanation

A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.

B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.

C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.

D. Grimacing is an objective observation by the nurse, not a subjective report from the client.

A. Severe pitting, very swollen leg and indentation that lasts for a long time, 8 mm deep B. Slight indentation, with no perceptible swelling of the leg. 2 mm deep C. Moderate pitting, with indentation that subsides rapidly, 4 mm deep D. Deep pitting, swollen leg, and indentation that remains for a short time, 6 mm deep

Correct Answer is A

Explanation

A. +4 pitting edema is characterized by severe pitting that creates a deep indentation (greater than 8 mm) that remains for a prolonged period. This description matches the findings in option

B. This describes +1 pitting edema, which is not consistent with +4 edema.

C. This option describes +2 or +3 pitting edema, as the indentation subsides rapidly, which does not align with +4.

D. Although this describes deep pitting, the depth is less than 8 mm, which is not consistent with +4 edema.

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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A nurse is assessing a client for manifestations of pain. Which finding is a subjective indicator of pain?

Correct Answer is C

Explanation

A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

Correct Answer is A

Explanation

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