A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

Observe the client's eye movements through the cardinal fields of vision.

Observe the client's pupillary response to a penlight.

Observe the client's optic disc through an ophthalmoscope.

Assess the client's ability to read a Snellen chart from a distance of 20 feet.

Answer and Explanation

The Correct Answer is D

A. Observe the client's eye movements through the cardinal fields of vision: This test evaluates extraocular muscle function and cranial nerves III, IV, and VI. It helps detect muscle weakness or nerve damage but does not measure visual acuity or diagnose legal blindness.

B. Observe the client's pupillary response to a penlight: This assesses the integrity of the optic and oculomotor nerves and reflexes, such as pupil constriction. While useful in neurological assessments, it does not determine the level of visual acuity needed to confirm legal blindness.

C. Observe the client's optic disc through an ophthalmoscope: Direct visualization of the optic disc can reveal issues like glaucoma or optic atrophy. However, it does not quantify vision loss or determine functional blindness as defined by acuity measurements.

D. Assess the client's ability to read a Snellen chart from a distance of 20 feet: This is the standard method for evaluating visual acuity. Legal blindness is defined in the U.S. as visual acuity of 20/200 or worse in the better eye with corrective lenses, making this test the most appropriate for supporting the client’s statement.

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Correct Answer is C

Explanation

A. Use a Doppler ultrasound to hear the heart beat: A Doppler ultrasound is typically used for assessing blood flow, not for auscultating heart sounds. It is not necessary for detecting an extra heart sound.

B. Auscultate for one minute with the stethoscope's diaphragm: The diaphragm of the stethoscope is better for high-pitched sounds, such as lung and heart murmurs, but it is not ideal for listening to low-pitched sounds, such as extra heart sounds. This could miss certain heart sounds.

C. Listen to the heart sounds using the bell of a stethoscope: The bell of the stethoscope is best for listening to low-pitched sounds, such as extra heart sounds (S3, S4, or murmurs). Using the bell helps the nurse detect these low-frequency sounds more effectively, making it the best action to verify the finding.

D. Obtain a pulse oximeter reading from two extremities: A pulse oximeter measures oxygen saturation and would not provide information regarding heart sounds. This action does not help in verifying the presence of extra heart sounds.

A. Collect information about the client's activities since surgery. B. Conduct a comprehensive review of systems. C. Prepare to collect a vaginal specimen for Papanicolaou smear. D. Perform a head-to-toe physical assessment.

Correct Answer is A

Explanation

A. Collect information about the client's activities since surgery: Focusing the history on the client’s recovery, current symptoms, physical activity tolerance, and any complications or concerns since the hysterectomy provides the most relevant information for a postoperative follow-up. This approach helps assess healing and identify any recovery issues.

B. Conduct a comprehensive review of systems: A full review of systems is more appropriate for an annual exam or initial assessment. For a focused postsurgical visit, the nurse should prioritize gathering data related to the surgical recovery rather than reviewing unrelated body systems.

C. Prepare to collect a vaginal specimen for Papanicolaou smear: A Pap smear may not be immediately necessary post-hysterectomy, depending on the type of hysterectomy performed and the client’s cancer risk. It is not a routine part of a 6-week postoperative evaluation unless specifically ordered by the HCP.

D. Perform a head-to-toe physical assessment: A complete physical exam is typically unnecessary at a routine postoperative check unless complications are suspected. A focused history and exam centered on the surgical site and recovery are more appropriate for this visit.

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A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Correct Answer is C

Explanation

A client reports to the healthcare provider's (HCP) office for a routine postsurgical evaluation six weeks after a hysterectomy. Which history taking approach should the nurse use to gather the needed information?

Correct Answer is A

Explanation

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