A patient has a normal corneal light reflex. The nurse recognizes that this reflex indicates which information about the eyes?

Choice A reason: Tenderness is assessed by palpation, not auscultation, which focuses on sounds. Auscultation precedes to avoid altering bowel sounds, so this is incorrect for the reason given.

Choice B reason: Patient relaxation is beneficial but not the primary reason for auscultation first. Preventing bowel sound distortion by avoiding percussion and palpation is key, so this is incorrect.

Choice C reason: Vascular sounds like bruits are less affected by percussion/palpation than bowel sounds. Bowel sound distortion is the main concern, so this is incorrect for the primary reason.

Choice D reason: Auscultation before percussion and palpation prevents distortion of bowel sounds, which can be altered by manipulation. This is the correct reason, reflecting proper abdominal assessment technique.

Choice A reason: Breathing difficulty is the highest priority, as it affects oxygenation, a life-threatening issue. Pain is next, impacting comfort and recovery, followed by sleep, which supports healing. This follows the ABC (Airway, Breathing, Circulation) prioritization, making it the correct order for addressing the patient’s issues.

Choice B reason: Prioritizing sleep over pain after breathing is incorrect; pain is more urgent, as it distresses and affects recovery, while sleep is secondary. Breathing remains first, but pain precedes sleep, so this is incorrect for prioritization.

Choice C reason: Sleep as the first priority ignores breathing, a critical life-threatening issue. Breathing and pain are more urgent, with sleep supporting long-term recovery, so this is incorrect for acute care prioritization principles.

Choice D reason: Placing sleep first and breathing last disregards life-threatening breathing issues. Breathing, then pain, then sleep align with ABC priorities, ensuring patient patient safety, so this is incorrect for the nurse’s approach.