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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.
Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Introducing oneself after entering the patient’s room is a key aspect of effective communication with a blind patient. This helps the patient identify who is in the room with them.
Choice B rationale
Using a firm, loud voice when addressing the patient is not necessarily effective. While it’s important to speak clearly, raising one’s voice can come off as patronizing or disrespectful. It’s better to speak in a normal tone and adjust as needed based on the patient’s feedback.
Choice C rationale
Lightly touching the patient’s arm can be an effective way to gain their attention, especially if they may not have heard you enter the room. However, it’s important to ask for consent before touching the patient.
Choice D rationale
Providing instructions in clear, simple terms can be very helpful for a blind patient. This can help them understand what is happening and what they need to do.
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