The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?

Document findings

Determine whether the patient can count fingers

Obtain a tumbling E chart to assess visual acuity

Complete an internal eye exam .

Answer and Explanation

The Correct Answer is B

Choice B rationale
If a patient states that he cannot see the top of the Snellen chart, the nurse should determine whether the patient can count fingers. If the patient is unable to read the top line of the Snellen

chart at 6 meters, the nurse can reduce the distance to 3 meters from the Snellen chart. If the patient still cannot read the chart, the nurse can then determine whether the patient can count fingers.
Choice A rationale
While documenting findings is an important part of the nursing process, it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice C rationale
Obtaining a tumbling E chart to assess visual acuity could be considered if the patient is unable to read letters or numbers, but it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice D rationale
Completing an internal eye exam would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.

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Correct Answer is A

Explanation

Choice A rationale

Eating food that is either very warm or very cold can trigger pain in individuals with trigeminal neuralgia. Therefore, if a client made this statement, it would indicate the need for further teaching.
Choice B rationale
Chewing on the unaffected side can help minimize episodes of pain in trigeminal neuralgia.
Choice C rationale
Rinsing the mouth if tooth brushing is too painful is a good strategy for managing trigeminal neuralgia.
Choice D rationale
Washing the face with cotton pads can help minimize episodes of pain in trigeminal neuralgia.

A. Arrange for the client to have visual acuity assessed. B. Facilitate tonometry testing C. Arrange for the client to be assessed for macular degeneration. D. Reassure the client that this is an age-related change in vision.

Correct Answer is C

Explanation

Choice A rationale
While assessing visual acuity may be part of a comprehensive eye examination, it would not specifically address distortions noted on the Amsler grid.
Choice B rationale
Tonometry testing is used to measure the pressure inside the eye and is typically used in the diagnosis of glaucoma. It would not specifically address distortions noted on the Amsler grid.
Choice C rationale
Distortions when looking at the Amsler grid can be a sign of macular degeneration16. Therefore, arranging for the client to be assessed for macular degeneration would be the appropriate action16.
Choice D rationale
While age-related changes in vision can occur, distortions when looking at the Amsler grid are not typically considered a normal age-related change16. Therefore, reassuring the client that this is an age-related change in vision would not be the appropriate action16.

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The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with trigeminal neuralgia has been given suggestions to minimize episodes of pain. Which statement, if made by the client, would indicate the need for further teaching?

Correct Answer is A

Explanation

A client has informed the Home Health Nurse that they recently noticed distortions when looking at the Amsler grid kept on their refrigerator. What is the appropriate action for the nurse to take?

Correct Answer is C

Explanation

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The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?