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 D

Explanation

Choice A rationale

Foreign body obstruction typically presents with sudden onset of choking, coughing, and respiratory distress, often following ingestion. While difficulty swallowing may be present, the primary signs are usually related to airway compromise rather than a muffled voice and fever. A muffled voice is more indicative of swelling affecting the vocal cords or surrounding structures.

Choice B rationale

A nasal polyp is an abnormal growth in the nasal passages, typically causing nasal congestion, reduced sense of smell, and postnasal drip. It would not cause a muffled voice or high fever, nor would it directly lead to severe difficulty swallowing, as it is anatomically located in the nasal cavity, separate from the pharynx and larynx.

Choice C rationale

A laryngeal polyp is a benign growth on the vocal cords, primarily causing hoarseness or voice changes. While it affects the voice, it does not typically cause a high fever or severe difficulty swallowing (dysphagia) unless it is exceptionally large and obstructing the pharynx, which is rare. The symptoms suggest a more inflammatory or infectious process.

Choice D rationale

Peritonsillar abscess is a collection of pus behind the tonsil, a common complication of pharyngitis. The inflammation and swelling can cause severe throat pain, difficulty swallowing (odynophagia and dysphagia), and trismus (difficulty opening the mouth). The muffled voice, often described as "hot potato voice," is characteristic due to swelling impinging on the pharynx and soft palate, altering vocal resonance.

A. Share personal values to put the client at ease. B. Begin with Questions that are less sensitive in nature. C. Get the most difficult Questions over with first. D. Ask Questions in a vague, nonspecific format.

Correct Answer is B

Explanation

Choice A rationale

Sharing personal values can shift the focus from the client's needs to the nurse's experiences, potentially making the client uncomfortable or less willing to share. Professional boundaries dictate that the nurse maintains objectivity and prioritizes the client's therapeutic relationship and psychological safety. This approach can be perceived as unprofessional and may hinder trust.

Choice B rationale

Starting with less sensitive questions allows for rapport building and establishes a trusting environment. This gradual approach respects the client's potential hesitancy regarding a sensitive topic like family mental health history. It helps to decrease anxiety and resistance, making it more likely the client will eventually feel comfortable discussing more difficult subjects. This aligns with the principle of progressive disclosure in therapeutic communication.

Choice C rationale

Immediately addressing highly sensitive topics can overwhelm the client, leading to defensiveness, withdrawal, or an unwillingness to continue the discussion. This direct approach disregards the client's emotional state and the need for a therapeutic alliance, which is crucial for effective communication about delicate personal information. It may also lead to the client shutting down.

Choice D rationale

Vague or nonspecific questions can lead to misinterpretation and do not elicit accurate or comprehensive information. Precise, yet open-ended, questions are essential for effective data collection in a health history. Ambiguity can frustrate the client and prevent the nurse from obtaining the specific details necessary for a thorough assessment, hindering diagnostic accuracy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse expect?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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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?