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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Assessing the client's functional capacity and identifying potential environmental hazards is essential, especially in older adults, as they may face physical limitations or risks in their environment that could impact their safety and quality of life.
B. Medication history is always important, particularly in older adults who may be taking multiple medications for chronic conditions. However, while relevant, it is not the most critical aspect in this scenario.
C. Differentiating between symptoms of aging and those caused by disease is important for accurate diagnosis and treatment. However, the priority should be to assess the client's overall health and risks related to their daily function and environment.
D. While discussing advance directives is essential for future care planning, it is not the immediate priority in this health history assessment. The focus should be on addressing any current health issues that impact the client’s quality of life.

A. Hernia. B. Aneurysm. C. Tympany. D. Appendicitis.

Correct Answer is B

Explanation

A. A hernia may present as a bulge in the abdomen, but it is not typically pulsating. It is usually a soft, non-pulsatile mass.
B. A pulsating centrally localized abdominal distention is characteristic of an abdominal aneurysm, which occurs when the wall of the aorta weakens and bulges. The pulsation is often palpable and can be dangerous if ruptured.
C. Tympany refers to a sound produced during percussion, which is typically heard over air-filled structures like the stomach, but it doesn’t cause pulsating distention.
D. Appendicitis typically presents with localized pain in the lower right abdomen and is not associated with pulsating abdominal distention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is A

Explanation

When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

Correct Answer is B

Explanation

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range: Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?

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?

An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect this client's sleep?

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?