A nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?

The pupils constrict when the examiner's index finger slowly moves toward the client's nose

The client's peripheral vision becomes sharper the examiner shines a light over the pupils

The pupils dilate when the examiner's finger slowly moves toward the client's nose

The client involuntary blinks in the of bright light directed the pupils during the eye exam

Answer and Explanation

The Correct Answer is A

A) The pupils constrict when the examiner's index finger slowly moves toward the client's nose: This is the correct description of the process of visual accommodation. Visual accommodation refers to the ability of the eyes to focus on a near object. When the examiner's finger is moved toward the client's nose, the pupils should constrict to focus the light on the retina. This response is an indicator that the client’s eyes are properly adjusting to focus on a close object.

B) The client's peripheral vision becomes sharper when the examiner shines a light over the pupils: This is not correct, as shining a light over the pupils is related to assessing the pupillary light reflex, not visual accommodation. Visual accommodation focuses on the ability to focus on a near object, while peripheral vision is related to the ability to see objects outside of the central vision, and is not influenced by the light shining directly into the pupil.

C) The pupils dilate when the examiner's finger slowly moves toward the client's nose: This is incorrect. When assessing visual accommodation, the pupils should constrict (become smaller) as the object moves closer to the face, not dilate. Dilation of the pupils would suggest a lack of accommodation and could indicate a neurological or eye condition.

D) The client involuntarily blinks in the presence of bright light directed at the pupils during the eye exam: This describes the corneal reflex, which is a response to bright light or a foreign object approaching the eye, rather than a test of visual accommodation. This reflex is mediated by the trigeminal nerve and is unrelated to the accommodation response, which focuses on the pupil's reaction to near objects.

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Correct Answer is D

Explanation

A) Crackles: Crackles are abnormal lung sounds often associated with conditions such as pneumonia, heart failure, or pulmonary edema. They result from fluid in the airways or alveoli. However, crackles are not typically the primary finding in pleuritis, which involves inflammation of the pleura.

B) Stridor: Stridor is a high-pitched wheezing sound caused by an obstruction or narrowing of the upper airway, often seen in conditions such as croup or anaphylaxis. It is not characteristic of pleuritis, which involves inflammation of the pleura and not airway obstruction.

C) Dyspnea: Dyspnea, or difficulty breathing, is a common symptom in many respiratory conditions, including pleuritis. While pleuritis can lead to discomfort during breathing, dyspnea itself is not a sound that would be auscultated. It’s a subjective feeling that would be noted during the client’s history or verbal report, rather than an auscultatory finding.

D) Friction rub: A pleural friction rub is the most expected finding when auscultating a client with pleuritis. This sound occurs when the inflamed pleural layers rub against each other during breathing, producing a grating, scratchy sound. The nurse will typically hear this sound best on inspiration or expiration and it is the hallmark sign of pleuritis. The presence of a friction rub indicates the pleural inflammation characteristic of this condition.

A. A blend of fibrous, glandular, and adipose tissues B. Primarily milk ducts which function a milk reservoirs C. Primarily muscle with small amounts of fibrous tissue D. Glandular tissue to attach the breast to the chest wall

Correct Answer is A

Explanation

A) A blend of fibrous, glandular, and adipose tissues: The internal structure of the breast is composed of a mixture of fibrous, glandular, and adipose tissues. The glandular tissue is responsible for producing milk, the fibrous tissue provides structural support, and the adipose tissue stores fat. This combination of tissues gives the breast its shape and functional capabilities, making it a complex and dynamic organ.

B) Primarily milk ducts which function as milk reservoirs: While the breast does contain milk ducts that transport milk from the glandular tissue to the nipple, it is not primarily composed of these ducts. The milk ducts are an important component, but they do not make up the majority of the breast's internal structure. The blend of different tissues is what defines the breast’s anatomy.

C) Primarily muscle with small amounts of fibrous tissue: The breast itself does not contain significant muscle tissue. The primary muscles related to the breast are the pectoral muscles, which lie beneath the breast tissue but are not part of the internal breast structure. The internal breast primarily consists of fibrous, glandular, and adipose tissues, not muscle.

D) Glandular tissue to attach the breast to the chest wall: The glandular tissue is crucial for milk production, but it does not function to attach the breast to the chest wall. The attachment of the breast to the chest wall is facilitated by the Cooper's ligaments, which are fibrous bands that help maintain structural integrity. Glandular tissue primarily serves the function of milk production.

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A nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?

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