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 C

Explanation

A. Percuss diaphragmatic excursion: Percussion of diaphragmatic excursion helps evaluate the movement of the diaphragm during respiration but does not directly confirm the physical appearance or structural change associated with a barrel chest.

B. Palpate tactile fremitus on the posterior chest: Tactile fremitus assesses vibration transmission through lung tissue and can indicate consolidation or air trapping, but it is not useful for visually confirming a barrel-shaped chest.

C. Observe the appearance of the thorax: A barrel chest is a visual and structural change where the chest appears rounded and expanded due to increased anterior-posterior (AP) diameter of the chest , often seen in chronic respiratory conditions like COPD. Observing the shape and configuration of the thorax is the most direct and accurate method to confirm this physical finding.

D. Auscultate the client's breath sounds: Auscultation reveals the presence or absence of breath sounds and abnormal respiratory patterns but does not provide confirmation of chest shape. It is valuable in assessing lung function, not thoracic structure.

A. Collect information about the client's activities since surgery. B. Conduct a comprehensive review of systems. C. Prepare to collect a vaginal specimen for Papanicolaou smear. D. Perform a head-to-toe physical assessment.

Correct Answer is A

Explanation

A. Collect information about the client's activities since surgery: Focusing the history on the client’s recovery, current symptoms, physical activity tolerance, and any complications or concerns since the hysterectomy provides the most relevant information for a postoperative follow-up. This approach helps assess healing and identify any recovery issues.

B. Conduct a comprehensive review of systems: A full review of systems is more appropriate for an annual exam or initial assessment. For a focused postsurgical visit, the nurse should prioritize gathering data related to the surgical recovery rather than reviewing unrelated body systems.

C. Prepare to collect a vaginal specimen for Papanicolaou smear: A Pap smear may not be immediately necessary post-hysterectomy, depending on the type of hysterectomy performed and the client’s cancer risk. It is not a routine part of a 6-week postoperative evaluation unless specifically ordered by the HCP.

D. Perform a head-to-toe physical assessment: A complete physical exam is typically unnecessary at a routine postoperative check unless complications are suspected. A focused history and exam centered on the surgical site and recovery are more appropriate for this visit.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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?

Correct Answer is A

Explanation

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

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.