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 D

Explanation

A. Blowing or hollow sounds above the sternum are abnormal and may suggest a condition like aortic or pulmonary disease. Such sounds are not typical during routine chest auscultation and may indicate pathology like bronchial obstruction or an abnormal vascular sound.
B. Slight crackling sounds, also known as "rales" or "crackles," may be indicative of fluid accumulation in the lungs, often seen in conditions like pneumonia or congestive heart failure. These are not considered normal findings and warrant further evaluation.
C. Faint whistling sounds may be indicative of wheezing, which is often a sign of airway narrowing or obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD). Wheezing is not typically considered normal and should be investigated further.
D. Right-sided breath sounds being louder than the left could be a normal finding in certain individuals, depending on factors like body position or anatomical variations. In a healthy individual, this difference may not indicate pathology unless associated with other symptoms such as asymmetry in lung sounds or dyspnea.

A. "It doesn't take much activity before I'm out of breath." B. "I sleep on three pillows at night." C. "I cough a lot at night and it keeps me up half the night." D. "I have multiple attacks of wheezing almost daily."

Correct Answer is B

Explanation

A. This statement could indicate exercise intolerance or shortness of breath with exertion, but it doesn't specifically relate to orthopnea. Orthopnea refers to difficulty breathing when lying flat, not with activity.
B. This statement is indicative of orthopnea. People with orthopnea often need to sleep with multiple pillows or sit up to relieve the shortness of breath they experience when lying flat, often due to heart failure or other respiratory conditions.
C. Nighttime coughing can be a symptom of various conditions, such as asthma or postnasal drip, but it is not specific to orthopnea. Orthopnea is more about difficulty breathing while lying down.
D. Wheezing is a sign of asthma or other respiratory conditions but does not directly correlate with orthopnea. Orthopnea is specifically about the inability to breathe comfortably when lying down, not about wheezing.

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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

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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