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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Romberg sign tests for balance, not responsiveness to stimuli.

B. Facial asymmetry may suggest a neurological issue, but it is not directly related to stupor.

C. Checking the pupillary response to light is important but does not specifically assess the level of consciousness or stupor.

D. Stupor is characterized by a state of near-unconsciousness, where the client is unresponsive to verbal stimuli but may respond to physical stimuli. Assessing the response to stimuli is the best way to confirm this condition.

A. Repeat the number "99" during a systematic auscultation of the thorax B. Whisper "one, two, three" in sequence during auscultation of the thorax. C. Repeat vocalizing the letter "E" while the thorax is auscultated. D. Breathe in and out while all lobes of both lungs are auscultated.

Correct Answer is C

Explanation

A. Repeat the number "99": This test is for bronchophony, not egophony.

B. Whisper "one, two, three": This tests for whispered pectoriloquy.

C. Repeat vocalizing the letter "E": Egophony is assessed by having the client say "E" while auscultating the thorax. In areas of lung consolidation (e.g., a lung abscess), "E" sounds may be heard as "A."

D. Breathe in and out: This assesses general breath sounds, not egophony.

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A client states, "l 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

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Correct Answer is D

Explanation

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Correct Answer is C

Explanation

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