The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Perform the confrontation test.

Ask the patient to read the print on a handheld Jaeger card.

Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

Use the Snellen chart positioned 20 feet away from the patient.

Answer and Explanation

The Correct Answer is D

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

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Correct Answer is C

Explanation

A. Fifth intercostal space, left of the midclavicular line: This placement is used to auscultate the mitral valve, which is best heard at the apex of the heart. The mitral valve sounds are typically heard around the fifth intercostal space, midclavicular line.

B. Left lower sternal border: This placement is used to auscultate the tricuspid valve, which is best heard at the lower left sternal border.

C. Second left intercostal space: This is the correct placement for auscultating the pulmonic valve. The pulmonic valve sounds are best heard at the second left intercostal space, which is close to the upper left sternal border.

D. Second right intercostal space: This placement is used to auscultate the aortic valve, which is best heard at the second right intercostal space, close to the upper right sternal border.

A. Discuss that a light will be directed at the neck to observe for pulsations of the artery B. instruct the client to take a deep breath and "hold" while the nurse briefly auscultates C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude D. Show the client the diaphragm of the stethoscope that will be placed on the neck

Correct Answer is C

Explanation

A. Discuss that a light will be directed at the neck to observe for pulsations of the artery:

This choice is incorrect. Directing light at the neck is not a standard method for assessing carotid artery pulsations. The carotid artery is usually assessed by palpation to feel the pulse rather than visual observation.

B. Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates:

This choice is incorrect. Auscultation is typically not used to assess carotid artery pulsations. Palpation (feeling the pulse) is the primary method used for this assessment.

C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude:

This choice is correct. Palpating both carotid arteries simultaneously allows the nurse to compare the amplitude (strength) of the pulses. This comparison helps in assessing the symmetry of the pulses and ensures there are no significant differences between the two sides, which could indicate vascular abnormalities.

D. Show the client the diaphragm of the stethoscope that will be placed on the neck:

This choice is incorrect. The diaphragm of the stethoscope is not typically used for palpating pulses. Palpation involves using the fingertips to feel the pulse and assess its strength and regularity.

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The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

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Naxlex Comprehensive Predictor Exams

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