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 ["A","B","D","E"]

Explanation

A) High cholesterol: Elevated cholesterol levels, particularly low-density lipoprotein (LDL) cholesterol, are a significant risk factor for cardiovascular disease. High cholesterol can lead to the buildup of plaques in the arteries, which increases the risk of heart attacks and strokes. Managing cholesterol through diet, exercise, and medication can reduce cardiovascular risk.

B) Diabetes: Diabetes, especially poorly controlled blood sugar levels, significantly increases the risk of cardiovascular disease. High blood glucose can damage blood vessels and nerves, leading to complications such as coronary artery disease and stroke. Effective management of diabetes through lifestyle changes and medication can help mitigate these risks.

C) Age: While age is a risk factor for cardiovascular disease, it is a non-modifiable factor. As people age, the risk of developing cardiovascular issues naturally increases due to changes in the cardiovascular system. Since age cannot be altered, it is not included in the list of modifiable risk factors.

D) Weight: Excess body weight, particularly obesity, is associated with an increased risk of cardiovascular disease. Obesity contributes to conditions like hypertension, diabetes, and dyslipidemia, all of which elevate cardiovascular risk. Weight management through diet, exercise, and healthy lifestyle choices is crucial for reducing this risk.

E) Smoking: Smoking is a major modifiable risk factor for cardiovascular disease. It damages the blood vessels, increases blood pressure, and reduces oxygen supply to the heart, contributing to the development of atherosclerosis and other cardiovascular conditions. Quitting smoking is one of the most effective ways to lower cardiovascular risk

A. Obtain a threat culture for possible streptococcal (strep) infection B. Continue with the assessment, looking for any other abnormal findings C. Refer the client to their primary provider D. No response is needed, this appearance is normal for the tonsils

Correct Answer is D

Explanation

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture for streptococcal infection is generally warranted when there are signs and symptoms of a bacterial infection, such as a sore throat, fever, exudate on the tonsils, or swollen lymph nodes. The description provided—involuted, granular tonsils with deep crypts—is a normal, age-related finding and not indicative of an infection. Therefore, obtaining a throat culture is unnecessary unless additional clinical signs of infection are present.

B) Continue with the assessment, looking for any other abnormal findings:
While it is always important to complete a thorough assessment and look for other abnormal findings, the specific characteristics described (involuted, granular tonsils with deep crypts) are normal, particularly in adults. This is a common finding and does not require further investigation unless accompanied by other symptoms such as pain, swelling, or visible pus, which would warrant a closer look.

C) Refer the client to their primary provider:
Referral to a primary provider is generally recommended if there are significant concerns about the tonsils, such as persistent swelling, pain, or signs of infection. However, the description provided does not suggest a pathological issue; these characteristics are typically considered normal in adults. Referral would only be necessary if additional concerning symptoms were present, such as fever, difficulty swallowing, or changes in voice.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Involuted (shrunken), granular tonsils with deep crypts are a normal, age-related finding, especially in adults. Over time, the tonsils tend to shrink and develop more pronounced crypts (pockets). This is part of the natural aging process and is not usually a sign of pathology. These tonsil changes are often seen in individuals who have had repeated infections or as part of the natural aging process.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse s teaching a group of clients about modifiable risk factors for cardiovascular disease. Which of the following should the nurse include in the teaching? (Select All that Apply).

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. The nurse should recognize that which of the following is the correct response to these findings?

Correct Answer is D

Explanation

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