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. Peristaltic waves: Visible peristaltic waves in adults may suggest an intestinal obstruction or other abnormal gastrointestinal motility. These waves might be seen in very thin individuals as slight rippling movements or those with serious digestive tract issues and require further diagnostic evaluation. However, prominent waves are not normal.

B. Heterogeneous color: Uneven or blotchy abdominal skin color may indicate bruising, poor circulation, inflammation, or underlying pathology. Such a finding is not typical and should prompt further assessment to rule out localized or systemic conditions.

C. Homogeneous color: A consistent, uniform skin tone across the abdomen is a normal finding and indicates healthy skin perfusion. This suggests that there is no localized inflammation, bruising, or vascular compromise present during inspection.

D. Masses: Palpable or visible abdominal masses are considered abnormal and can be associated with tumors, hernias, or organ enlargement. The discovery of a mass necessitates further diagnostic tests to determine its cause and clinical significance.

A. Likely onset of Parkinson's disease. B. Need for a walker to aid in ambulation. C. Expected results for an older adult. D. Increased risk for falling.

Correct Answer is D

Explanation

A. Likely onset of Parkinson's disease: The Tinetti assessment evaluates gait and balance in older adults to identify those at an increased risk of falling but is not diagnostic for Parkinson’s disease. While Parkinson’s can affect gait and balance, a low score alone does not confirm its presence and further neurological evaluation would be necessary.

B. Need for a walker to aid in ambulation: A low Tinetti score may lead to recommending assistive devices like a walker, but the test itself doesn’t directly indicate the need for one. A comprehensive mobility and safety assessment is needed before prescribing mobility aids.

C. Expected results for an older adult: Although balance and gait may decline with age, a combined Tinetti score of 20 (balance 12 + gait 8) is considered low and indicates a significant deviation from safe functional mobility in older adults, rather than an expected finding.

D. Increased risk for falling: A Tinetti total score below 19 suggests a high risk for falls. This client’s score of 20 is just above that critical threshold but still considered moderate risk, clearly indicating impaired mobility and a heightened risk of falling.

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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 C

Explanation

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Correct Answer is D

Explanation

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