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 D

Explanation

A. Right side deep tendon reflex 2+: A 2+ reflex is considered normal and would not correlate with the nurse’s observation of diminished reflexes. Documenting 2+ would fail to reflect the neurological deficit noted in the assessment.

B. Right side deep tendon reflex 0: A 0 reflex indicates complete absence of a response, suggesting flaccid paralysis or severe lower motor neuron damage. The nurse observed diminished reflexes, not absent, so 0 would overstate the impairment.

C. Right side deep tendon reflex 4+: A 4+ reflex indicates hyperreflexia, often associated with upper motor neuron lesions, not weakness and diminished reflexes. This would contradict the nurse’s findings of decreased neuromuscular activity on the right side.

D. Right side deep tendon reflex 1+: A 1+ rating represents diminished or hypoactive reflexes, which aligns with the nurse’s findings of generalized weakness and reduced deep tendon activity. This accurately reflects the likely residual neurological effects post-CVA.

A. Right breath sounds louder than left. B. Slight crackling throughout lung fields. C. Faint whistling over both lung bases. D. Blowing, hollow sounds above sternum.

Correct Answer is D

Explanation

A. Right breath sounds louder than left: While there might be slight variations, breath sounds should generally be equal in intensity on both sides of the chest. Breath sounds should be relatively equal bilaterally. Asymmetry in sound intensity can indicate consolidation, obstruction, or a pneumothorax.

B. Slight crackling throughout lung fields: Crackles (rales) are abnormal sounds typically associated with fluid in the alveoli, as seen in conditions like heart failure, pneumonia, or pulmonary fibrosis. They are not a normal finding in healthy lung tissue.

C. Faint whistling over both lung bases: Whistling or high-pitched sounds suggest wheezing, often caused by narrowed airways due to asthma, bronchitis, or other obstructive airway diseases. This is considered an abnormal finding.

D. Blowing, hollow sounds above sternum: These describe bronchial breath sounds, which are normally heard over the trachea and manubrium (above the sternum). They have a blowing, hollow quality and are considered a normal finding in that location.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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