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 A

Explanation

A. Instruct client to demonstrate activities of daily living: Assessing the ability to perform activities of daily living (ADLs) such as bathing, dressing, toileting, and feeding is essential when determining if an older adult can safely live in an assisted living environment. ADL performance directly impacts the level of care and support required.

B. Screen client for alcohol or controlled drug abuse: While substance use screening is important for overall health evaluation, it is not the primary assessment when determining suitability for assisted living. It may be part of a broader psychosocial evaluation.

C. Focus questions to evaluate long term memory: Long-term memory evaluation is relevant in assessing cognitive function, but it does not fully reflect the client’s ability to manage daily tasks required for independent or semi-independent living.

D. Evaluate client for side effects of routine medications: Monitoring medication side effects is important for safety, but it does not directly measure functional capacity to live in an assisted setting. ADL capability remains the most critical factor for admission decisions.

A. Clean the ears to remove excess wax build up. B. Culture the white patches for possible fungal growth. C. Referral to an audiologist for a hearing evaluation. D. Record the findings in the client's record.

Correct Answer is D

Explanation

A. Clean the ears to remove excess wax build up: There is no indication of cerumen (ear wax) occlusion based on the visual inspection. The tympanic membranes are clearly visible, suggesting that the ear canals are not obstructed by wax.

B. Culture the white patches for possible fungal growth: Fungal infections of the ear (otomycosis) typically involve the external auditory canal, not the tympanic membrane itself. The patches described are more consistent with tympanosclerosis, which does not require culturing.

C. Referral to an audiologist for a hearing evaluation: While chronic ear infections can affect hearing, the client denies any hearing loss, and the tympanic membranes appear otherwise healthy. There is no immediate need for audiologic referral unless symptoms arise.

D. Record the findings in the client's record: The dense white patches are likely tympanosclerosis, a common, benign finding resulting from scarring due to past ear infections. No treatment is needed if the client is asymptomatic. Proper documentation is the appropriate next step.

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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

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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