A nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Use the Snellen chart positioned 20 feet away from the client

Determine the client’s ability to read newsprint at a distance of 12 to 14 inches

Perform the confrontation test

Ask the client to read the print on a handheld jaeger card

Answer and Explanation

The Correct Answer is A

A) Use the Snellen chart positioned 20 feet away from the client:
This is the correct method for assessing visual acuity in adults. The Snellen chart is the standard tool used to measure visual acuity at a distance. The client is positioned 20 feet away from the chart, and they are asked to read the smallest line of letters they can clearly identify. The result is typically documented as a fraction (e.g., 20/20), where the numerator represents the distance from the chart, and the denominator represents the distance at which a person with normal vision can read the same line. This test assesses distance vision and is essential for checking overall visual sharpness.

B) Determine the client’s ability to read newsprint at a distance of 12 to 14 inches:
This is not used to assess visual acuity; it assesses near vision and can be part of the overall vision examination, but it is not the standard method for testing visual acuity. Typically, the near vision assessment is done with tools like a Jaeger chart or by asking the client to read newsprint at a standard reading distance (12 to 14 inches), but this is not the primary test for visual acuity. The Snellen chart is specifically for distance vision.

C) Perform the confrontation test:
The confrontation test is used to assess the visual fields, not visual acuity. It is a quick screening to determine if the client has any peripheral vision loss, where the nurse and the client compare their visual fields by covering one eye at a time and identifying moving fingers in the periphery. While important, this test does not assess the sharpness or clarity of central vision, which is the focus of a visual acuity test.

D) Ask the client to read the print on a handheld Jaeger card:
The Jaeger card is used to assess near vision, not visual acuity. It is used for clients who may have difficulty reading small print at a normal reading distance and helps assess presbyopia (difficulty focusing on near objects with age). However, this test is for near vision and is not the primary test for visual acuity, which typically focuses on distance vision.

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Correct Answer is B

Explanation

A) Bronchial sounds:
Bronchial breath sounds are normal over the trachea and large bronchi but are considered abnormal if heard over the peripheral lung fields. In the case of pneumonia or other types of lung consolidation, bronchial sounds may be transmitted to more peripheral areas of the lungs where they are typically not heard. However, bronchial sounds themselves are not the specific adventitious sound produced by lung consolidation, though their presence can suggest consolidation.

B) Crackles:
Crackles (also known as rales) are the adventitious sounds most commonly associated with lung consolidation, such as in pneumonia. Crackles occur when air bubbles move through the fluid or mucus in the alveoli and small airways. In pneumonia, the inflammation and accumulation of fluid or pus in the alveoli (consolidation) causes crackling or popping sounds during inspiration. Crackles are a key indicator of consolidation in the lungs, making this the correct choice.

C) Whispered pectoriloquy:
Whispered pectoriloquy is a type of vocal fremitus that can be heard during auscultation when the patient whispers a phrase. It is an abnormal finding that can occur in the presence of lung consolidation, where the whispered sounds are heard more clearly or louder than normal. While it is related to lung consolidation, it is not an adventitious sound like crackles. Instead, it is a sign that can indicate the presence of consolidation when paired with other findings like bronchophony.

D) Bronchophony:
Bronchophony is the increased clarity and intensity of spoken sounds during auscultation, which occurs in areas of lung consolidation. When a patient says "99," the sound may become more distinct and louder when consolidation is present. Although bronchophony is another finding that may suggest consolidation, it is a vocal sound rather than an adventitious breath sound. Bronchophony refers specifically to changes in voice transmission, not to the crackling or popping sounds caused by consolidation itself.

A. Whisper random numbers letters, then have the client repeat them B. Shield the lips so that the sound is muffled C. Stand approximately 4 feet away from the client D. Have the client place a finger in the ear canal to occlude outside noise

Correct Answer is A

Explanation

A) Whisper random numbers and letters, then have the client repeat them:
This is correct. The voice test is a simple way to assess a client's hearing. The nurse should stand about 2 feet away from the client and whisper random numbers or letters. The client should repeat what they hear. This test checks the ability to hear and distinguish sounds, particularly for high-frequency tones. It's an effective screening method for detecting hearing loss.

B) Shield the lips so that the sound is muffled:
This is incorrect. The nurse should not shield their lips during the voice test because it could interfere with the client's ability to hear and potentially read the nurse's lips, which can help with understanding. The client should be allowed to observe lip movements to aid in comprehension of the sounds being spoken.

C) Stand approximately 4 feet away from the client:
This is incorrect. The recommended distance for performing the voice test is typically around 2 feet, not 4 feet. Standing too far away can make it more difficult for the client to hear the whispered numbers or letters and could affect the accuracy of the test. The nurse should stand close enough (about 2 feet) to ensure that the sound is audible to the client but not too close as to distort the test.

D) Have the client place a finger in the ear canal to occlude outside noise:
This is incorrect. While the client should be instructed to avoid distractions or loud environments during the test, placing a finger in the ear canal is not necessary. The test assesses the client's ability to hear sound, and occluding the ear could affect the results. The client should simply be in a quiet environment.

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A nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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