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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Heel-to-shin tests cerebellar coordination, not balance like Romberg’s. It assesses motor precision, not proprioception or vestibular function, which Romberg’s targets by checking sway with eyes closed, making this technique irrelevant to the intended assessment here.

Choice B reason: Walking on heels and toes evaluates motor strength and coordination, not stationary balance. Romberg’s tests proprioceptive stability, not gait, missing the core focus on vestibular and sensory integration critical to this neurological balance assessment fully.

Choice C reason: Romberg’s test assesses balance by having the client stand, feet together, eyes open then closed for 20 seconds. Sway with eyes closed indicates proprioceptive or vestibular issues, making this the precise, standard technique for this evaluation accurately.

Choice D reason: Finger-to-thumb tests fine motor skills and coordination, not balance. Romberg’s focuses on postural stability via sensory input, not hand dexterity, rendering this action unrelated to assessing the client’s equilibrium as intended in this context completely.

A. Blood is returning from the client's toe more slowly than normal. B. There is a disruption in osmotic pressure in the client's extremities. C. There is a blockage or infection in the client's lymphatic system. D. The client's toe is receiving an inadequate supply of blood.

Correct Answer is D

Explanation

Choice A reason: Slow venous return causes edema, not deep, painful wounds. This venous issue lacks the arterial insufficiency link to tissue necrosis, misaligning with the circular ulcer’s ischemic profile, which requires oxygen delivery, not just drainage, here fully.

Choice B reason: Osmotic pressure disruption affects fluid balance, not localized wounds. This systemic issue doesn’t explain a toe ulcer’s depth and pain, missing the vascular supply deficit driving tissue breakdown in this specific extremity finding entirely and clearly.

Choice C reason: Lymphatic blockage or infection causes swelling or lymphangitis, not deep, circular wounds. This lacks the ischemic etiology of toe ulcers, which stem from arterial insufficiency, not lymphatic dysfunction, distinguishing it from the observed pathology here fully.

Choice D reason: Inadequate arterial blood supply, as in peripheral artery disease, causes deep, painful toe ulcers due to tissue ischemia. Poor oxygen delivery leads to necrosis, matching the wound’s characteristics, making this the most likely etiology accurately and precisely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the Romberg's test on a patient. Which is the correct technique for conducting this?

Correct Answer is C

Explanation

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Correct Answer is D

Explanation

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