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 D

Explanation

A. While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B. Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C. Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D. The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

A. Battle sign. B. Chvostek's sign. C. Romberg sign. D. Babinski sign.

Correct Answer is C

Explanation

A. Battle sign refers to bruising behind the ears and is a sign of head trauma, not intoxication.
B. Chvostek's sign is related to hypocalcemia, not intoxication.
C. Romberg sign assesses for balance issues when standing with eyes closed and is commonly positive in clients with neurological impairment, including intoxication.
D. Babinski sign is related to neurological disorders and would not be directly associated with intoxication.

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

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Correct Answer is C

Explanation

While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.