After checking a client's pupillary response to light, the practical nurse (PN) tells the registered nurse (RN) that the client’s pupils are constricted with minimal response to light.
Before verifying the PN’s findings, which action should the RN take?

Administer PRN saline eye solution.

Review the client’s medication list.

Brighten the light in the client’s room.

Assess the client’s visual fields.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering PRN saline eye solution would not address the underlying cause of constricted pupils or provide diagnostic information. Saline solution is primarily used for lubrication or to flush irritants, and its application here would not be a scientific approach to understanding a neurological finding. Pupil constriction can indicate various physiological or pharmacological effects, requiring a more thorough investigation.

Choice B rationale

Medications, especially opioids or certain miotics, can cause pupillary constriction (miosis) by stimulating parasympathetic pathways, leading to acetylcholine release and sphincter pupillae contraction. Conversely, some medications affect adrenergic receptors, influencing pupil size. Reviewing the medication list is a crucial scientific step in differentiating between drug-induced miosis and a pathological neurological condition, ensuring patient safety and appropriate intervention.

Choice C rationale

Increasing the light intensity would typically cause further pupillary constriction through the pupillary light reflex, mediated by the optic and oculomotor nerves. However, if the pupils are already minimally responsive due to a physiological or pharmacological cause, brightening the light would not provide additional diagnostic information or elucidate the reason for the initial constricted state.

Choice D rationale

Assessing visual fields evaluates the integrity of the optic pathways and can detect deficits like scotomas or hemianopsia. While vision is related to pupillary function, assessing visual fields directly would not explain or verify constricted pupils with minimal light response. Pupillary abnormalities primarily indicate issues with the afferent (optic nerve) or efferent (oculomotor nerve) limbs of the pupillary reflex arc, not necessarily the entire visual field.

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Correct Answer is C

Explanation

Choice A rationale

Whispering "one, two, three" is a technique used to assess for whispered pectoriloquy. This phenomenon occurs when whispered words are heard distinctly through the stethoscope, indicating consolidation in the lung parenchyma. While useful for identifying lung pathology, it specifically targets sound transmission of quiet speech, not the characteristic "E" to "A" sound change of egophony.

Choice B rationale

Breathing in and out during auscultation allows the nurse to listen to normal breath sounds and detect adventitious sounds like crackles, wheezes, or rhonchi, which are indicative of various respiratory conditions. However, this general breathing instruction does not specifically elicit the voice changes required to assess for egophony, which involves vocalization.

Choice C rationale

Egophony is an abnormal voice sound characterized by a nasal or bleating quality, often described as an "E" sounding like "A.”. This phenomenon occurs due to altered sound transmission through consolidated lung tissue, which acts as a filter, preferentially transmitting higher frequencies and altering vowel sounds. Instructing the client to repeat "E" allows the nurse to identify this specific acoustic change.

Choice D rationale

Repeating "99" during auscultation is the instruction given to assess for bronchophony. Bronchophony is present when spoken words are heard more loudly and clearly through the stethoscope over areas of lung consolidation, indicating enhanced sound transmission due to increased tissue density. While both egophony and bronchophony suggest consolidation, they are distinct auditory phenomena elicited by different vocalizations.

A. Headaches. B. Intercostal retractions. C. Peripheral edema. D. Dyspnea.

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

Explanation

Choice A rationale

Headaches are a common symptom with various etiologies, including hypertension, stress, or dehydration, but they are not a classic or specific indicator of heart failure exacerbation. While a client with heart failure might experience headaches, it does not directly confirm the worsening of cardiac function or fluid overload. Therefore, it is not a primary diagnostic criterion for exacerbation.

Choice B rationale

Intercostal retractions signify increased work of breathing due to airway obstruction or lung compliance issues, often observed in severe respiratory distress associated with heart failure exacerbation. This physiological response indicates significant effort to move air, suggesting pulmonary congestion and reduced lung capacity secondary to fluid accumulation in the alveoli. It is a critical objective sign.

Choice C rationale

Peripheral edema, particularly in the lower extremities, is a hallmark sign of right-sided heart failure. It results from increased hydrostatic pressure in the capillaries, forcing fluid into the interstitial spaces due to the heart's inability to effectively pump blood forward. This fluid retention confirms systemic volume overload, indicative of worsening heart failure.

Choice D rationale

Dyspnea, or shortness of breath, is a cardinal symptom of heart failure, especially when exacerbated. It arises from pulmonary venous congestion and increased fluid in the interstitial spaces of the lungs, impairing gas exchange. The sensation of breathlessness, particularly with exertion or at rest, directly reflects compromised cardiac output and fluid overload.

Choice E rationale

Jugular venous distension (JVD) is a direct clinical manifestation of elevated central venous pressure, a key indicator of right-sided heart failure and fluid volume overload. When the heart struggles to pump blood effectively, blood backs up into the venous system, causing the jugular veins to become visibly engorged, confirming an exacerbation.

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After checking a client's pupillary response to light, the practical nurse (PN) tells the registered nurse (RN) that the client’s pupils are constricted with minimal response to light. Before verifying the PN’s findings, which action should the RN take?

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Naxlex Comprehensive Predictor Exams

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Correct Answer is C

Explanation

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm(s) to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

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

Explanation

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?

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While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

After checking a client's pupillary response to light, the practical nurse (PN) tells the registered nurse (RN) that the client’s pupils are constricted with minimal response to light.
Before verifying the PN’s findings, which action should the RN take?