A nurse documents that the client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

The eyes converge to focus on the light.

The eye focuses the image in the center of the pupil.

Dilation of both pupils occurs in response to bright light.

Constriction of both pupils occurs in response to bright light.

Answer and Explanation

The Correct Answer is D

A. The eyes converge to focus on the light.

This statement refers to the convergence reflex, where both eyes move medially (towards each other) to maintain single binocular vision when focusing on a near object. It is not related to the pupillary light reflex, which involves changes in pupil size in response to light.

B. The eye focuses the image in the center of the pupil.

This choice does not accurately describe the pupillary light reflex. The pupillary light reflex involves constriction of the pupil in response to light, not focusing an image in the center of the pupil.

C. Dilation of both pupils occurs in response to bright light.

This statement is incorrect. In response to bright light, the pupils should constrict, not dilate. Dilation of pupils in bright light could indicate an abnormal response, such as in cases of certain neurological conditions or drug use.

D. Constriction of both pupils occurs in response to bright light.

This choice is correct. In the pupillary light reflex, both pupils constrict when exposed to bright light. This response is a protective mechanism to prevent excessive light from entering the eyes, ensuring optimal visual acuity.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Listening for all possible sounds at a time at each specified area: This approach does not allow for specific localization of different heart sounds and murmurs, making it difficult to accurately assess the heart's condition.

B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This option is close but lacks the systematic approach of method D. Listening at specific anatomical locations (aortic, tricuspid, pulmonic, mitral) is important, but the Z pattern allows for thorough coverage and precise localization of any abnormal sounds.

C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest: This method does not cover all the important auscultation sites on the heart and may miss significant findings.

D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex: This technique involves a systematic approach where the nurse listens at specific locations in a structured manner, ensuring comprehensive coverage of the heart sounds and murmurs.

A. AV node-SA node bundle of His- bundle branches B. SA node- AV node-bundle of His -bundle branches C. Bundle of His- AV node- SA node- Erb's Point D. AV node-SA node-bundle of His- Erb's Point

Correct Answer is B

Explanation

A. AV node - SA node - bundle of His - bundle branches:

This sequence is incorrect. The SA node (sinoatrial node) initiates the electrical impulse in the heart, followed by the AV node (atrioventricular node), bundle of His, and then the bundle branches.

B. SA node - AV node - bundle of His - bundle branches:

This sequence is correct. The electrical stimulus of the cardiac cycle starts at the SA node, which is the natural pacemaker of the heart. From the SA node, the impulse travels to the AV node, then to the bundle of His, and finally to the bundle branches, which distribute the impulse to the ventricles, causing them to contract.

C. Bundle of His - AV node - SA node - Erb's Point:

This sequence is incorrect. Erb's Point is a point on the chest where heart sounds S2 and S3 can be heard most distinctly.

D. AV node - SA node - bundle of His - Erb's Point:

This sequence is incorrect. The AV node comes after the SA node in the electrical conduction system of the heart. Erb's Point is not a part of the normal cardiac conduction pathway; it is a location for auscultation on the chest.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse documents that the client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?

Correct Answer is D

Explanation

The nurse is reviewing the sequence of the cardiac cycle. The nurse recognizes that the electrical stimulus of the cardiac cycle follows which sequence?

Correct Answer is B

Explanation

The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

The nurse is assessing the tonsils of an adult client. The nurse notices that the tonsils are involuted, granular in appearance, and has deep crypts. The nurse recognizes that which of the following is the correct response to these findings?

A nurse is reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

The nurse is performing an assessment of the client's mouth. The nurse recognizes that the tissue that connects the tongue to the floor of the mouth is the:

The nurse is performing a breast examination on a client. The nurse understands that examining the upper outer quadrant of the breast is especially important because this part is:

The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?

The nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse recognizes that which of the following is considered an abnormal finding?

Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)