A client states, "I 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.

Observe the client's optic disc through an ophthalmoscope.

Observe the client's eye movements through the cardinal fields of vision.

Assess the client's ability to read a Snellen chart from a distance of 20 feet.

Answer and Explanation

The Correct Answer is D

A.   Observing pupillary response to a penlight helps assess the neurological function related to the eyes, such as reaction to light, but it does not directly assess the client's overall visual acuity or support the claim of being legally blind.
B.   Examining the optic disc can help identify structural changes in the eye, such as damage to the retina or optic nerve, but it doesn't directly assess the client’s claim of being legally blind or the extent of visual impairment.
C.   Assessing eye movements can help evaluate for conditions such as strabismus or cranial nerve abnormalities, but it doesn't provide a direct assessment of visual acuity or support the client’s statement of blindness.
D.   The Snellen chart is a standard tool for assessing visual acuity and is the most appropriate method to objectively measure whether the client has the visual impairment consistent with being legally blind.

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Correct Answer is A

Explanation

A. Icterus, or yellowing of the sclera, is a key sign of jaundice, which occurs when there is an excess of bilirubin in the blood.
B. Serum bilirubin levels are important for diagnosis but are not an immediate physical assessment.
C. Dark urine can suggest liver or bile duct issues but is not definitive for jaundice.
D. Pallor of the conjunctiva indicates anemia, not jaundice.

A. Palpate the radial pulses in both arms for a deficit. B. Use the stethoscope to listen over the carotid artery. C. Feel the volume of the dorsalis pedis and posterior tibialis pulses. D. Auscultate the apical pulse at the point of maximal impulse.

Correct Answer is D

Explanation

A. Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B. Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C. Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D. Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

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A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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