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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Guarding refers to voluntary or involuntary muscle contraction of the abdominal wall in response to pain or inflammation. This is assessed through palpation, where the nurse feels for muscle rigidity, not through auscultation, which involves listening to internal sounds.
Choice B rationale
Ascites, the accumulation of fluid in the peritoneal cavity, is primarily detected through inspection (distended abdomen), palpation (fluid wave, shifting dullness), and percussion. Auscultation is not the primary method for identifying the presence of free fluid in the abdominal cavity.
Choice C rationale
Striae, commonly known as stretch marks, are linear streaks or bands on the skin resulting from rapid stretching. These are visual findings, assessed through inspection of the skin surface, and cannot be detected by auscultation, which relies on sound perception.
Choice D rationale
Bruits are abnormal vascular sounds, often described as swishing or humming, produced by turbulent blood flow through a narrowed or dilated artery. Auscultation with a stethoscope is the appropriate technique to detect these sounds over abdominal arteries, indicating potential vascular abnormalities.
Correct Answer is B
Explanation
Choice A rationale
Cleaning the ears to remove excess wax buildup is inappropriate here because the description explicitly states the tympanic membranes (TMs) are visible and translucent gray, indicating no significant wax obstruction. Ear wax, or cerumen, naturally protects the ear canal; excessive buildup typically manifests as obscured TMs or hearing impairment, neither of which is present.
Choice B rationale
Recording the findings in the client's record is the most appropriate action. The presence of dense white patches on the tympanic membranes, known as tympanosclerosis, is a common sequela of chronic otitis media and typically represents calcification within the TM, not active infection or hearing loss. Given no current symptoms, this is an expected, benign finding.
Choice C rationale
Culturing the white patches for possible fungal growth is not indicated. Tympanosclerosis is a non-infectious, degenerative process involving hyaline degeneration and calcification of the TM, often following inflammation. Fungal infections of the ear typically present with different characteristics, such as otorrhea, pruritus, or pain, none of which are reported here.
Choice D rationale
Referral to an audiologist for a hearing evaluation is not immediately necessary. The client reports no hearing loss, and while tympanosclerosis can sometimes impact hearing, especially if extensive, the current lack of symptoms and clear visualization of landmarks suggest a stable, non-acute condition. An audiogram would be indicated if hearing changes were reported.
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