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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Schedule a follow-up appointment in one month: Delaying evaluation of an enlarged thyroid may result in a missed or late diagnosis of serious conditions such as hyperthyroidism, hypothyroidism, or thyroid nodules. Immediate further assessment is needed rather than waiting.

B. Obtain a dietary consultation for nutrition teaching: While dietary factors, especially iodine deficiency, can contribute to thyroid enlargement, nutritional counseling should follow diagnostic clarification. It is not the first priority when a structural abnormality is found.

C. Instruct the client in the need to use iodized salt: This may be appropriate if iodine deficiency is confirmed, but assuming the cause without testing may lead to inappropriate interventions. Not all goiters are due to iodine deficiency, and some may be caused by autoimmune or neoplastic conditions.

D. Request diagnostic laboratory testing for the client: Ordering thyroid function tests (e.g., TSH, T3, T4) is essential to determine the underlying cause of the enlargement. Depending on these results, further testing like thyroid antibodies or imaging studies (ultrasound, thyroid scan) might be necessary. Laboratory evaluation helps guide further management, whether it is medication, imaging, or referral to endocrinology.

A. Peristaltic waves. B. Heterogeneous color. C. Homogeneous color. D. Masses.

Correct Answer is C

Explanation

A. Peristaltic waves: Visible peristaltic waves in adults may suggest an intestinal obstruction or other abnormal gastrointestinal motility. These waves might be seen in very thin individuals as slight rippling movements or those with serious digestive tract issues and require further diagnostic evaluation. However, prominent waves are not normal.

B. Heterogeneous color: Uneven or blotchy abdominal skin color may indicate bruising, poor circulation, inflammation, or underlying pathology. Such a finding is not typical and should prompt further assessment to rule out localized or systemic conditions.

C. Homogeneous color: A consistent, uniform skin tone across the abdomen is a normal finding and indicates healthy skin perfusion. This suggests that there is no localized inflammation, bruising, or vascular compromise present during inspection.

D. Masses: Palpable or visible abdominal masses are considered abnormal and can be associated with tumors, hernias, or organ enlargement. The discovery of a mass necessitates further diagnostic tests to determine its cause and clinical significance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. Which action should the nurse take in response to this finding?

Correct Answer is D

Explanation

The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

A client reports to the healthcare provider's (HCP) office for a routine postsurgical evaluation six weeks after a hysterectomy. Which history taking approach should the nurse use to gather the needed information?

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?

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

To confirm the presence of a barrel chest documented in the client's medical record, which action should the nurse take?