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. The eye focuses the image in the center of the pupil B. Constriction both pupils occurs in response to bright light C. The eye focuses the light on the sclera D. Dilation of both pupils occurs in response to bright light

Correct Answer is B

Explanation

A) The eye focuses the image in the center of the pupil:
This option describes the accommodation reflex, not the pupillary light reflex. The accommodation reflex involves the focusing of the eye to bring an image to the center of the retina, but it does not relate to the constriction of the pupils in response to light. Therefore, it is not the correct answer for describing the pupillary light reflex.

B) Constriction of both pupils occurs in response to bright light:
This is the correct description of the pupillary light reflex. When light is shined into one eye, the normal response is for both pupils (direct and consensual response) to constrict. The pupillary light reflex tests the integrity of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III), which control the constriction of the pupil in response to light. A normal pupillary light reflex is characterized by the constriction of both pupils when exposed to light.

C) The eye focuses the light on the sclera:
This statement is inaccurate. The sclera is the white part of the eye, and light is focused on the retina (specifically the fovea) for proper vision. This does not relate to the pupillary light reflex, which specifically refers to the constriction of the pupils in response to light.

D) Dilation of both pupils occurs in response to bright light:
This is incorrect. Dilation of the pupils occurs in low light conditions as part of the pupillary dilation reflex (also called the "dark reflex") to allow more light into the eye. However, in response to bright light, the pupils constrict, not dilate. The constriction of the pupils in bright light is the primary characteristic of a normal pupillary light reflex.

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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

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Explanation

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Correct Answer is B

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