Question

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?

- pupil clarity
- visual fields
- visual acuity

Answer 1

To identify an older client's safety needs and assess their risk for falls, a nurse should use visual acuity, visual fields, and pupil clarity assessments.

Step-by-step explanation:

When assessing an older client's risk for falls, a nurse should use the following assessments to identify the client's safety needs:

1. Visual acuity: This assessment measures the client's ability to see clearly and identify small details at a certain distance. The Snellen chart is commonly used to test visual acuity.
2. Visual fields: This assessment determines the boundaries of the client's peripheral vision. By holding their hands out to either side, the nurse can ask the client when their fingers are no longer visible without moving their eyes to track them.
3. Pupil clarity: This assessment is done through physical inspection of the optic disk using an ophthalmoscope. It helps detect any abnormalities in the optic nerve.