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 B

Explanation

A. Record this normal finding in the assessment record: An enlarged lymph node is not a normal finding and should not be recorded as such. It may indicate an infection, inflammation, or other underlying conditions. Further investigation is required to determine the cause of the enlargement.

B. Ask the client about any localized tenderness at the site: Assessing tenderness in the enlarged lymph node helps the nurse gather information about the potential cause. Tender lymph nodes are often associated with infections or inflammation, while non-tender nodes may indicate other issues, such as malignancy. This assessment is crucial in guiding further action.

C. Auscultate the lymph node for the presence of a bruit: A bruit is an abnormal sound that indicates turbulent blood flow and is typically heard over arteries, not lymph nodes. Auscultating a lymph node for a bruit is not relevant to this assessment.

D. Cover the inflamed area and notify the healthcare provider: While notifying the healthcare provider may be necessary later, the immediate priority is to assess the lymph node's characteristics, including tenderness and any other related symptoms, to guide appropriate action. Simply covering the area without further assessment would delay the necessary evaluation.

A. Repeat vocalizing the letter "E" while the thorax is auscultated. B. Whisper "one, two, three" in sequence during auscultation of the thorax. C. Repeat the number "99" during a systematic auscultation of the thorax. D. Breathe in and out while all lobes of both lungs are auscultated.

Correct Answer is A

Explanation

A. Repeat vocalizing the letter "E" while the thorax is auscultated: Egophony is assessed by having the client say "E" while the nurse auscultates the chest. In the presence of lung consolidation, such as in a lung abscess, the "E" sound may be auscultated as an "A"—a finding known as the "E-to-A" change, which is a hallmark of egophony.

B. Whisper "one, two, three" in sequence during auscultation of the thorax: This technique is used to assess whispered pectoriloquy, not egophony. It helps detect areas of lung consolidation if whispered words are heard clearly through the stethoscope.

C. Repeat the number "99" during a systematic auscultation of the thorax: This test is used to assess bronchophony, increased loudness and clarity of spoken words, another sign of lung consolidation. Clear transmission of "99" may suggest fluid or consolidation in the lungs.

D. Breathe in and out while all lobes of both lungs are auscultated: This is a standard part of respiratory assessment but is not specific for egophony. It helps detect abnormal breath sounds like wheezes, crackles, or diminished sounds, not vocal resonance changes.

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

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Correct Answer is B

Explanation

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Correct Answer is A

Explanation

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 conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

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?

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

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?

When assessing a client's mouth, which finding requires immediate follow-up by the nurse?

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?