On inspection, which client does the nurse suspect of having a visual impairment?

Correct Answer: C

Rationale: The client who is tilting their head (Choice C) is the correct answer because head tilting is a common compensatory behavior observed in individuals with visual impairments, particularly those with refractive errors, strabismus, or unilateral vision loss. Tilting the head adjusts the angle of gaze to optimize visual input, minimize double vision, or align the eyes to use the best-functioning part of the retina. For example, a person with astigmatism may tilt their head to reduce blur, while someone with a muscle imbalance (e.g., superior oblique palsy) may adopt an abnormal head posture to maintain binocular vision. This behavior is a clear clinical indicator of visual difficulty and warrants further assessment. Choice A (the client whose sclera is white) is incorrect because a normal, white sclera is a sign of ocular health, not impairment. Pathological conditions affecting vision—such as cataracts, glaucoma, or retinal disorders—do not typically alter scleral color. While abnormalities like jaundice (yellow sclera) or redness (indicating inflammation) may suggest systemic or localized issues, they are not direct markers of visual acuity loss. A white sclera alone provides no diagnostic value for visual impairment. Choice B (the client who has an intact blink reflex) is incorrect because the blink reflex is a protective, involuntary response mediated by cranial nerves (V and VII) and does not correlate with visual acuity. An intact blink reflex merely confirms normal corneal sensitivity and brainstem function. Individuals with severe visual impairments, including blindness, often retain this reflex. Conversely, its absence (e.g., in facial nerve palsy) does not imply vision loss. This choice distracts from genuine signs of visual dysfunction. Choice D (the client with equal pupils) is incorrect because pupil equality (isocoria) is a normal finding and does not rule out visual impairment. Pupillary size and symmetry assess the autonomic nervous system and optic nerve function but are unrelated to refractive errors, macular degeneration, or other common causes of vision loss. Unequal pupils (anisocoria) may indicate neurological issues (e.g., Horner’s syndrome) but are not specific to visual acuity deficits. Equal pupils lack relevance in identifying clients needing vision-related interventions. In summary, head tilting (C) is the only behavior directly linked to adaptive strategies for visual challenges, while the other options reflect normal physiological states or unrelated neurological functions. Recognizing such compensatory behaviors is critical for early detection and intervention in clients with visual impairments.

Correct Answer: D

Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.

Correct Answer: A

Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.

Correct Answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

Correct Answer: C

Rationale: The correct answer is C: Lower the intraocular pressure. The primary objective of treating glaucoma is to reduce intraocular pressure to prevent further vision loss. Choice A, 'Improve the vision of the eye,' is incorrect because while treatment may prevent vision loss, it does not necessarily improve vision. Choice B, 'Strengthen the muscles of the eye,' is incorrect as glaucoma primarily involves the optic nerve and not muscle weakness. Choice D, 'Dry up excess secretions,' is not related to the treatment goal of glaucoma which is focused on managing intraocular pressure.