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

Observe the client's pupillary response to a penlight.

Observe the client's optic disc through an ophthalmoscope.

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

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.   Observing pupillary response to a penlight helps assess the neurological function related to the eyes, such as reaction to light, but it does not directly assess the client's overall visual acuity or support the claim of being legally blind.
B.   Examining the optic disc can help identify structural changes in the eye, such as damage to the retina or optic nerve, but it doesn't directly assess the client’s claim of being legally blind or the extent of visual impairment.
C.   Assessing eye movements can help evaluate for conditions such as strabismus or cranial nerve abnormalities, but it doesn't provide a direct assessment of visual acuity or support the client’s statement of blindness.
D.   The Snellen chart is a standard tool for assessing visual acuity and is the most appropriate method to objectively measure whether the client has the visual impairment consistent with being legally blind.

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Correct Answer is B

Explanation

A. While subjective data is important, it should be categorized appropriately based on relevance to the diagnosis, not just placed in the notes section without context.
B. Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
C. Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as
entering information directly in the client’s electronic medical record with appropriate organization.
D. Documenting assessment findings at the nursing station might delay real-time recording and cause the information to be less accurate, especially if not recorded immediately after assessment.

A. Palpating in the wrong abdominal quadrant. B. The gallbladder is normal. C. The client is too obese. D. Deeper palpation technique is needed.

Correct Answer is C

Explanation

A. While it is important to palpate the correct quadrant, this is unlikely the cause if the gallbladder cannot be located. The gallbladder is typically located in the right upper quadrant, and the nurse would have been palpating this area. This option does not address the most likely cause.
B. A normal gallbladder might not always be palpable, especially if the client is obese. However, inability to palpate the gallbladder does not necessarily indicate a problem; this is a common finding in obese individuals where fat tissue can obscure the gallbladder.
C. Obesity can make it more difficult to palpate internal structures such as the gallbladder. Excess adipose tissue in the abdominal area can prevent the nurse from feeling the gallbladder during palpation. This is the most likely explanation for the failure to locate the gallbladder.
D. While deeper palpation might be necessary in obese clients, the inability to palpate the gallbladder is more likely due to the obscuring effects of fat, rather than a technique issue. It's a common finding that obesity hinders the ability to palpate organs like the gallbladder.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Correct Answer is B

Explanation

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is C

Explanation

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