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

Assess the client's ability to read a Snellen chart from a distance of 20 feet.

Observe the client's optic disc through an ophthalmoscope.

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

Observe the client's pupillary response to a penlight.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Legal blindness is clinically defined as a corrected visual acuity of 20/200 or less in the better eye, or a visual field of 20 degrees or less. The Snellen chart directly assesses visual acuity by requiring the client to identify letters of decreasing size at a standardized distance of 20 feet. This method directly measures the client's ability to discern detail at a distance, which is the primary parameter for legal blindness.

Choice B rationale

Observing the optic disc with an ophthalmoscope primarily assesses the health of the optic nerve and retinal vasculature, which can indicate conditions like glaucoma or diabetic retinopathy. While these conditions can lead to visual impairment, ophthalmoscopy itself does not directly quantify visual acuity or field deficits. It is a structural assessment, not a functional visual acuity measurement.

Choice C rationale

Observing cardinal fields of vision assesses extraocular muscle function and cranial nerve integrity. This technique helps identify nystagmus, strabismus, or gaze palsies. While these conditions can affect visual function and coordination, they do not directly measure the degree of central visual acuity required to determine legal blindness. It assesses eye movement, not visual clarity.

Choice D rationale

Observing pupillary response to a penlight assesses the function of the oculomotor nerve (cranial nerve III) and the integrity of the afferent and efferent pathways of the pupillary light reflex. Abnormal responses can indicate neurological issues or eye pathology. However, pupillary response does not directly measure visual acuity or visual field, which are the diagnostic criteria for legal blindness.

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Correct Answer is D

Explanation

Choice A rationale

Diminished appetite can be a symptom of various conditions, including gastrointestinal issues, psychological factors, or systemic illness, but it does not directly indicate a change in bone density. While chronic poor nutrition can impact bone health over time, a recent change in appetite alone is not a primary screening criterion for immediate bone density assessment.

Choice B rationale

Significant weight loss, while a general indicator of health changes, does not directly signal a need for bone density screening. It can result from various factors, including intentional dieting, illness, or metabolic changes. While severe underweight can contribute to osteoporosis risk, a 15 lb weight loss in isolation isn't a direct trigger for screening.

Choice C rationale

A lower body mass index (BMI) can indicate underweight, which is a risk factor for osteoporosis due to decreased mechanical loading on bones and potential nutritional deficiencies. However, a lower BMI alone does not immediately necessitate a bone density screening unless it falls into a critically low range or is accompanied by other specific risk factors.

Choice D rationale

A decrease in height in an adult, especially an older adult female, is a significant indicator of potential vertebral compression fractures, a hallmark of osteoporosis. This loss of height suggests a reduction in bone mass and structural integrity, prompting the need for a bone density screening to assess for osteopenia or osteoporosis. Normal height can vary greatly.

A. Condition of hair, nails, and skin. B. History of a recent weight loss. C. Status of current appetite. D. A 24-hour diet history.

Correct Answer is D

Explanation

Choice A rationale

The condition of hair, nails, and skin can offer clues about chronic nutritional deficiencies (e.g., brittle nails for iron deficiency, dry skin for vitamin A deficiency, dull hair for protein-energy malnutrition). However, these are often non-specific and can be influenced by other factors like environmental exposure or systemic diseases, making them less precise indicators of overall or acute nutritional status.

Choice B rationale

A recent weight loss history can suggest inadequate caloric intake or increased metabolic demand, potentially indicating a decline in nutritional status. However, weight loss can also be intentional or due to non-nutritional factors like dehydration or acute illness, providing an incomplete picture without understanding the underlying cause or specific dietary patterns.

Choice C rationale

Appetite status provides subjective information about a person's desire to eat and can be influenced by transient factors like stress, illness, or recent food intake. While changes in appetite may accompany nutritional alterations, a good or poor appetite alone does not quantitatively or qualitatively describe the adequacy of nutrient consumption over a sustained period.

Choice D rationale

A 24-hour diet history is a comprehensive, objective method for assessing recent dietary intake by detailing all foods and beverages consumed over a specific 24-hour period. This allows for calculation of caloric and nutrient intake, providing the most accurate and quantifiable assessment of current nutritional status and identifying potential deficiencies or excesses.

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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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