Correct Answer: B

Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health. A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment. C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses. D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.

Correct Answer: A

Rationale: The correct answer is A: The nurse should practice interviewing strategies. This is the best remedy because improving the nurse's ability to gather comprehensive information during client history will ensure sufficient data for planning interventions. By practicing interviewing strategies, the nurse can learn to ask relevant questions, actively listen, and probe for additional details. Summary: B: Modifying the data collection tool may not address the issue of insufficient information if the problem lies with how the nurse conducts the interview. C: Determining the specific purpose of data collection is important but may not solve the immediate issue of lacking information for intervention planning. D: Updating the database is irrelevant to the problem of inadequate data collection during client history.

Correct Answer: C

Rationale: The correct answer is C: 1” to 1.5”. When irrigating a colostomy, the client should insert the lubricated catheter about 1” to 1.5” into the stoma. This depth allows for effective irrigation of the colon without causing discomfort or damage. Inserting the catheter too shallow (choice A) may not reach the colon, while inserting it too deep (choices B and D) can cause injury or perforation. Therefore, the optimal depth of 1” to 1.5” ensures proper irrigation while minimizing risks of complications.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern. Incorrect choices: A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem. C: Making accurate interpretations of data comes after data collection and analysis, not as the first step. D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.

Correct Answer: B

Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health. A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment. C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses. D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.