The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is B
Explanation
A. Observing for facial symmetry assesses cranial nerves VII (facial nerve), not cranial nerve III.
B. Cranial nerve III (oculomotor nerve) is responsible for eye movement and pupillary response, making checking the pupillary response to light the correct action.
C. Testing visual acuity primarily assesses cranial nerve II (optic nerve), not cranial nerve III.
D. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
Correct Answer is A
Explanation
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.