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) Demonstrate that both arteries will be palpated simultaneously to compare amplitude: This is not recommended. Palpating both carotid arteries simultaneously can cause a decrease in blood flow to the brain, potentially leading to dizziness or syncope. It is important to palpate one carotid artery at a time to avoid reducing blood flow to the brain, especially in clients with cardiovascular disease or those at risk of stroke.

B) Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates: This is the correct approach. Instructing the client to hold their breath helps minimize any interference from respiratory sounds while auscultating the carotid arteries for bruits. This technique ensures that breath sounds do not mask any abnormal vascular sounds, such as bruits, which could indicate a blockage or narrowing of the carotid arteries.

C) Discuss that a light will be directed at the neck to observe for pulsations of the artery: Observing pulsations with light is not an appropriate technique for assessing the carotid arteries. Pulsations may be visible in some cases, but palpation and auscultation are the more reliable methods for evaluating the carotid arteries for abnormalities such as bruits or reduced pulse amplitude.

D) Show the client the diaphragm of the stethoscope that will be placed on the neck: While it is appropriate to explain the process to the client, the action of showing the stethoscope is unnecessary at this stage. The focus should be on instructing the client to hold their breath for proper auscultation to listen for any abnormal vascular sounds.

A. Listening for sounds from the apex to the heart to the base of the heart. B. Listening to the sounds at the site where the apical pulse is heard to be the loudest. C. Listening from the base of the heart across and down, then over to the apex. D. Listening to the sounds at the aortic, tricuspid, pulmonic, arid mitral areas.

Correct Answer is D

Explanation

A) Listening for sounds from the apex to the heart to the base of the heart: This technique is not the most effective for auscultation of heart sounds. While it may seem logical to start at the apex and move toward the base, heart sounds are best heard at specific anatomical locations where the valves are closest to the chest wall. Moving from apex to base does not follow the traditional systematic approach used to assess all heart sounds.

B) Listening to the sounds at the site where the apical pulse is heard to be the loudest: The apical pulse is typically located at the mitral area (left 5th intercostal space, midclavicular line), and while this is an important location for assessing heart sounds, it is not the recommended approach for auscultation. The nurse should listen to all the key valve areas to fully assess the heart's function and detect abnormalities such as murmurs or extra heart sounds.

C) Listening from the base of the heart across and down, then over to the apex: This approach is not systematic and may cause the nurse to miss important sounds in the other areas of the heart. The base of the heart is located at the top (around the second intercostal space), while the apex is at the bottom (left 5th intercostal space). A more structured method of auscultation is required to ensure all key areas are evaluated.

D) Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This is the correct technique for auscultating heart sounds. The nurse should listen over the aortic, pulmonic, tricuspid, and mitral valve areas in sequence to assess heart sounds thoroughly. Each of these areas is associated with a specific valve, and auscultation at these locations helps the nurse identify any abnormal heart sounds, such as murmurs, S3, or S4, as well as the timing of S1 and S2 heart sounds. This systematic approach ensures a comprehensive assessment of heart function.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is D

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