A client states, "l 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.
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.
The Correct Answer is B
A. Observing the pupillary response to a penlight assesses the direct and consensual light reflex, not visual acuity.
B. Snellen chart testing is the standard method for assessing visual acuity and can help support the claim of legal blindness.
C. Observing the optic disc through an ophthalmoscope evaluates the internal eye structures but does not directly assess visual acuity.
D. Observing the cardinal fields of vision tests eye movements but does not evaluate overall visual acuity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Tympany refers to a hollow, drum-like sound heard on percussion, indicating air in the abdomen but not a pulsating mass.
B. A pulsating, centrally localized abdominal distention is most concerning for an abdominal aortic aneurysm (AAA), which can be life-threatening if it ruptures.
C. Hernia typically presents as a bulging mass but does not usually cause pulsation.
D. Appendicitis usually causes localized pain in the right lower quadrant, not pulsating distention.
Correct Answer is B
Explanation
A. Cessation of menstruation is a hallmark of menopause, not perimenopause.
B. Drenching night sweats are a common symptom of perimenopause, signaling changes in hormone levels and the transition to menopause.
C. Excessive vaginal moisture is not typically associated with perimenopause, which can cause dryness due to hormonal fluctuations.
D. An increase in sexual desire is not a typical symptom of perimenopause, which often leads to decreased libido due to hormonal changes.
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