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?

Review the client's medication list.

Assess the client's visual fields.

Brighten the light in the client's room.

Administer PRN saline eye solution.

Answer and Explanation

The Correct Answer is A

A. Review the client's medication list: Certain medications such as opioids, cholinergics, or miotic eye drops can cause pupillary constriction and sluggish reactivity. Reviewing the client’s medication profile can help determine if the abnormal pupillary response is pharmacologically induced or a sign of a neurological problem.

B. Assess the client's visual fields: Visual field testing evaluates peripheral vision and is not directly related to assessing pupillary response. This would not provide immediate insight into the cause of constricted pupils and is not the priority action in this situation.

C. Brighten the light in the client's room: While lighting can affect pupil size during assessment, constricted pupils with minimal response typically indicate an internal cause rather than poor lighting. Brightening the room may not significantly alter findings or explain the abnormal response.

D. Administer PRN saline eye solution: Saline eye drops may relieve dryness or irritation but have no effect on pupil size or reactivity. Administering them does not address the root cause of constricted pupils and could delay proper assessment and treatment.

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Correct Answer is D

Explanation

A. Clean the ears to remove excess wax build up: There is no indication of cerumen (ear wax) occlusion based on the visual inspection. The tympanic membranes are clearly visible, suggesting that the ear canals are not obstructed by wax.

B. Culture the white patches for possible fungal growth: Fungal infections of the ear (otomycosis) typically involve the external auditory canal, not the tympanic membrane itself. The patches described are more consistent with tympanosclerosis, which does not require culturing.

C. Referral to an audiologist for a hearing evaluation: While chronic ear infections can affect hearing, the client denies any hearing loss, and the tympanic membranes appear otherwise healthy. There is no immediate need for audiologic referral unless symptoms arise.

D. Record the findings in the client's record: The dense white patches are likely tympanosclerosis, a common, benign finding resulting from scarring due to past ear infections. No treatment is needed if the client is asymptomatic. Proper documentation is the appropriate next step.

A. An odorless, red menstrual blood flow. B. Cramping associated with the amount of flow. C. Blood clots sized at 0.5 cm (0.2 in) with menstrual flow. D. Blood saturation of one pad an hour.

Correct Answer is D

Explanation

A. An odorless, red menstrual blood flow: This is considered a normal characteristic of menstruation. Menstrual blood may have a slight metallic scent due to the mixing with vaginal secretions, but an odorless red flow is not a concern and does not suggest abnormality.

B. Cramping associated with the amount of flow: Mild to moderate cramping (dysmenorrhea) is a common and expected part of menstruation related to the release of prostaglandins that cause uterine contractions especially during heavier flow days. While it can be uncomfortable, it is not typically considered abnormal unless severe or disabling.

C. Blood clots sized at 0.5 cm (0.2 in) with menstrual flow: Small blood clots can occur during menstruation, especially during heavier flow, and clots under 1 inch (2.5 cm) in diameter are generally not worrisome. This size is within normal limits and not an indication of a menstrual disorder.

D. Blood saturation of one pad an hour: This finding suggests menorrhagia, or abnormally heavy menstrual bleeding. Saturating a pad or tampon every hour for several consecutive hours is clinically significant and warrants further investigation, as it can lead to anemia and may signal an underlying gynecological issue such as fibroids or a bleeding disorder.

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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

Correct Answer is D

Explanation

The nurse examines a client who is concerned about the amount of menstrual flow she is having. Which finding indicates an abnormality related to the client's current menstruation?

Correct Answer is D

Explanation

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

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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?

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.