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. Soft, barely heard on auscultation in a quiet room. B. Moderately loud, machine-like rumble, not associated with a thrill. C. Loud, at the apex, associated with a palpable thrill. D. Very loud, with no stethoscope, thrill easily palpable, heave visible.

Correct Answer is C

Explanation

A. Soft, barely heard on auscultation in a quiet room: This description refers to a murmur of a lower grade, Grade I, not a grade IV murmur. Grade I murmurs are very faint and may not be heard in all positions. A grade IV murmur is typically loud enough to be heard clearly and would likely be associated with a palpable thrill, which is not consistent with a soft murmur.

B. Moderately loud, machine-like rumble, not associated with a thrill: This description does not align with a grade IV systolic murmur, which is generally louder and more associated with a palpable thrill. A machine-like rumble could be indicative of a Grade III murmur or a different type of murmur, possibly related to other valvular conditions, but it would not match the characteristics of a grade IV systolic murmur.

C. Loud, at the apex, associated with a palpable thrill: A grade IV systolic murmur is loud and often associated with a palpable thrill, which can be felt at the apex of the heart, particularly in mitral valve regurgitation. This finding is consistent with the characteristics of a grade IV murmur and accurately reflects its clinical presentation.

D. Very loud, with no stethoscope, thrill easily palpable, heave visible: This description refers to a grade V or grade VI murmur, which is very loud and can be heard without a stethoscope. It also includes the visible heave, which is not typical for a grade IV murmur. Therefore, this is too extreme for the situation described.

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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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