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 A

Explanation

Choice A rationale

This open-ended question encourages the client to provide a comprehensive list of all medications, both prescription and over-the-counter, that they have used for their cough. This approach minimizes leading the client and maximizes the opportunity for the client to recall and articulate their complete medication history, including dosage and duration.

Choice B rationale

This question is broad and asks about all current medications, which may not specifically focus on the chronic cough. While important for a general medication history, it might not elicit the specific information needed regarding therapies used *for the cough*, potentially missing medications taken in the past or those specifically targeting the cough.

Choice C rationale

This is a closed-ended question that elicits a "yes" or "no" response. While it confirms prescription medication use, it does not encourage the client to elaborate on the specific names, dosages, or effectiveness of those medications, thereby limiting the depth of information obtained about their chronic cough management.

Choice D rationale

This question is very specific and focuses only on generic brands of cough syrup, which is a narrow scope. It might inadvertently exclude information about brand-name medications, other forms of cough medications (e.g., pills, inhalers), or other types of treatments the client may have tried for their chronic cough, thus limiting a full history.

A. Obtain a medication history including prescription and non-prescription drugs. B. Distinguish between symptoms caused by disease and those due to aging. C. Conduct an assessment of functional capacity and environmental hazards. D. Emphasize the need to place advance directives in the medical record.

Correct Answer is A

Explanation

Choice A rationale

Obtaining a comprehensive medication history, encompassing both prescription and non-prescription drugs, is paramount for older adults. Polypharmacy is common in this population, and drug-drug interactions, adverse effects, and medication non-adherence can significantly impact health outcomes and complicate existing conditions. This assessment helps identify potential issues like drug-induced constipation or interactions affecting blood pressure management.

Choice B rationale

While distinguishing symptoms caused by disease from those due to aging is important for accurate diagnosis and management, it is secondary to understanding the client's current medication regimen. Medications can mask or mimic age-related changes, making a clear medication history essential for proper differentiation.

Choice C rationale

Assessing functional capacity and environmental hazards is crucial for promoting safety and independence in older adults. This includes evaluating activities of daily living and identifying fall risks. However, addressing immediate physiological impacts and potential drug-related issues through a medication history takes precedence in an initial health history.

Choice D rationale

Emphasizing the need for advance directives is an important aspect of holistic care for older adults, respecting their autonomy in healthcare decisions. However, during a routine follow-up, it is not the most immediate or critical piece of information to obtain compared to the current physiological impact of medications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which query by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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