A nurse is completing a full assessment for their client on a telemetry unit. During the eye exam, a nurse shines a light into one of the client's eyes and the pupil of the other eye constricts. What is the most appropriate description of this finding?
Convergent response
Direct reflex
Consensual response
Accommodation
The Correct Answer is C
Choice A reason: Convergent response isn’t a standard term; convergence occurs with near focus, not light. This misnames the pupil constriction in the opposite eye from light stimulus, unrelated to the observed cranial nerve III reflex entirely here.
Choice B reason: Direct reflex is pupil constriction in the lit eye, not the other. This describes the same-side reaction, not the contralateral constriction observed, distinguishing it from the finding in this eye exam fully and accurately here.
Choice C reason: Consensual response is when light in one eye constricts the other’s pupil, via cranial nerve III. This matches the finding, reflecting normal optic and oculomotor nerve interplay, making it the precise description comprehensively here.
Choice D reason: Accommodation adjusts focus for near vision, constricting pupils bilaterally, not from unilateral light. This involves lens change, not the light-induced contralateral reflex seen, excluding it as the correct term in this scenario fully here.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: The base of the skull houses occipital nodes, not submental ones, which drain the lower face. Palpating here misses the submental region, irrelevant to sinus or throat infections, misaligning with lymphatic drainage patterns in this case.
Choice B reason: The angle of the jaw targets submandibular nodes, not submental, which sit midline under the chin. This area drains the jaw and mouth but not specifically the submental zone tied to the client’s symptoms directly.
Choice C reason: Behind the chin tip is the submental node location, draining the lower lip, tongue, and anterior mouth. With sinus and throat infection, this spot is key for detecting lymphadenopathy linked to the client’s fever and elevated WBC.
Choice D reason: Behind the ears assesses postauricular nodes, unrelated to submental drainage of the chin and mouth. This misses the infection’s likely lymphatic response, focusing on a region not typically involved in sinus or throat pathology here.
Correct Answer is D
Explanation
Choice A reason: Acute otitis media shows a red, bulging tympanic membrane due to bacterial infection and pus. A pearly gray, shiny appearance contrasts this, indicating no acute inflammation or fluid, ruling out this active middle ear condition entirely.
Choice B reason: Serous otitis media presents with amber fluid behind a retracted or neutral tympanic membrane, not pearly gray and shiny. This suggests no sterile effusion, distinguishing it from the normal, healthy membrane observed in this inspection clearly.
Choice C reason: Scarring from past infections appears as white, opaque patches on the tympanic membrane, not uniform pearly gray shininess. This finding lacks the irregular, thickened look of scar tissue, pointing to an unscathed membrane instead here.
Choice D reason: A pearly gray, shiny tympanic membrane is normal, reflecting light off an intact, healthy eardrum. This lacks signs of infection or fluid, aligning with standard anatomy where the membrane’s cone of light confirms its integrity fully.
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