Page 1973 - Saunders Comprehensive Review For NCLEX-RN

are then tested together. Visual acuity is measured with or without corrective lenses,
and the client stands at a distance of 20 feet (6 meters) from the chart.
Test-Taking Strategy: Remember that normal visual acuity as measured by a
Snellen chart is 20/20 vision. This should assist in eliminating options 3 and 4,
because they are comparable or alike in that they indicate standing at a distance of
40 feet (12 meters). From the remaining options, remember that it is best and most
accurate to test each eye separately and then test both eyes together.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Health Assessment/Physical Exam: Eye
Health Problem: N/A
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Jarvis (2016), pp. 289-290, 303.

693. Answer: 2

Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20
feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A
client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters)
what a person with normal vision can read at 60 feet (18 meters). With this vision,
the client may need glasses while driving in order to read signs and to see far ahead.
The client should be instructed to sit in the front of the room for lectures to aid in
visualization. This is not considered to be legal blindness.
Test-Taking Strategy: Focus on the subject, interpreting a Snellen chart result.
Note the test result, 20/60, and recall the associated interventions for this result. Also,
eliminate options 1 and 3, as they are comparable or alike, implying that the test
results indicate blindness.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Health Assessment/Physical Exam: Eye
Health Problem: Adult Health: Eye: Visual problems/refractive errors
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Lewis et al. (2017), p. 356.

694. Answer: 3

Rationale: Speaking in a normal tone to the client with impaired hearing and not
shouting are important. The nurse should talk directly to the client while facing the
client and speak clearly. If the client does not seem to understand what is said, the
nurse should express it differently. Moving closer to the client and toward the better
ear may facilitate communication, but the nurse should avoid talking directly into
the impaired ear.
Test-Taking Strategy: Focus on the subject, an effective communication technique
for the hearing impaired. Remember that it is important to speak in a normal tone.
Level of Cognitive Ability: Applying

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