2023 NGN ATI Comprehensive Predictor Exam New
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A nurse is assessing an older client's risk for falls. Which of the following assessments
should the nurse use to identify the client's safety needs? SATA
A. Lacrimal apparatus
B. Pupil clarity
C. visual fields
D. visual acuity
E. appearance of bulbar conjunctivae --------- Correct Answer --------- Answer:
pupil clarity
visual fields
visual acuity
Rationale:
Pupil clarity: Cloudy pupils mean that the client has cataracts. This makes vision cloudy
and creates halos around lights, which can increase the risk for falls because the client
cannot see items in their pathway clearly.
Visual fields: the nurse should use a finger to test the client's peripheral vision by
moving the finger out of range and then back into the visual field to determine when the
client sees the finger. Clients who have a visual field impairment are at an increased
risk for falls because they might not see objects outside of their central vision and trip
over them or bump into them and fall.
Visual acuity: the nurse should use the Snellen chart to assess distance vision and a
handheld card to assess near vision. Clients who wear eyeglasses should wear them
during the assessments. clients who have impaired visual acuity are at an increased
risk for falls because they might not see objects in their path and trip over them or bump
into them and fall.
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