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. Nasal polyps: Nasal polyps are soft, noncancerous growths in the nasal passages or sinuses, often linked to chronic inflammation, asthma, or allergies. They do not cause sore throat, fever, or difficulty swallowing, and are not associated with strep pharyngitis.

B. Laryngeal polyps: Laryngeal polyps typically present with hoarseness due to vocal cord involvement but are not associated with high fever, painful swallowing, or infections like streptococcal pharyngitis. They are usually non-infectious and develop gradually.

C. Foreign body obstruction: A foreign body obstruction causes sudden onset symptoms such as choking, coughing, or respiratory distress. This does not align with a progressive infectious presentation like fever and muffled voice, which suggests a localized infection.

D. Peritonsillar abscess: A peritonsillar abscess is a common complication of untreated or severe streptococcal pharyngitis. It presents with high fever, difficulty swallowing (dysphagia), muffled or "hot potato" voice, and unilateral throat pain due to pus collection near the tonsils.

A. Urinary frequency, unsteady gait, dental enamel erosion. B. Breast tenderness, tremors, high blood pressure. C. Vaginal discharge, presence of genital warts, abdominal tenderness. D. Body weight, hirsutism, thyroid enlargement.

Correct Answer is D

Explanation

A. Urinary frequency, unsteady gait, dental enamel erosion: These findings may suggest a urinary tract infection, neurological issue, or an eating disorder like bulimia. However, none are directly linked to amenorrhea in the context of a negative pregnancy test and recent missed periods.

B. Breast tenderness, tremors, high blood pressure: These symptoms could suggest hyperthyroidism or hormonal imbalance, but they are less specific to the cause of missed periods in this scenario compared to more directly relevant signs like weight or thyroid size.

C. Vaginal discharge, presence of genital warts, abdominal tenderness: These findings are related to sexually transmitted infections or gynecologic conditions, but the client has not had recent intercourse, and her main concern is amenorrhea, making these findings less relevant.

D. Body weight, hirsutism, thyroid enlargement: These are key assessment points when evaluating causes of amenorrhea. Low or high body weight can disrupt hormonal balance, hirsutism may indicate polycystic ovary syndrome (PCOS), and thyroid enlargement could suggest a thyroid disorder both common causes of menstrual irregularities in young women.

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

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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