A nurse is precepting a nursing student. The nurse explains to the nursing student how you would perform the graphesthesia test on a client. What is the correct way to perform this test?
The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred.
The nurse will briefly touch the client, and the client will need to identify where the touch occurred.
Client will close their eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.
The Correct Answer is C
A. This description relates more to a sensory discrimination test, not graphesthesia.
B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.
C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.
D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.
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Correct Answer is D
Explanation
A. Presbyopia refers to age-related difficulty in seeing close objects due to loss of elasticity in the lens, not distance vision.
B. Astigmatism is a condition caused by an irregular curvature of the eye, leading to blurred vision at any distance.
C. Hyperopia (farsightedness) is the inability to see close objects clearly, not distant ones.
D. Myopia (nearsightedness) is the condition where a person cannot see objects at a distance clearly, making it the correct term for this finding.
Correct Answer is ["A","C","D"]
Explanation
A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.
B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.
C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.
D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.
E. Religion: This does not relate to the clinical findings associated with pneumonia.
F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.
G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.