The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

Anisocoria of the patient's pupils.

Patient's accommodation response.

Direct pupil response of the patient.

Patient's consensual reflex.

Answer and Explanation

The Correct Answer is B

A: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.

B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A: Rales are described as fine crackling sounds, not high-pitched crowing.

B: Stridor is a high-pitched, wheezing sound heard primarily during inhalation and is often caused by an obstruction in the upper airway.
C: Wheezes are typically associated with asthma and are musical in nature, occurring mostly during exhalation.
D: Rhonchi are low-pitched sounds that resemble snoring and are caused by obstructions in the larger airways.

A. Check the blood pressure with the client in a supine position. B. Place the client in a sitting position. C. Determine the client's blood pressure 1 min after each position change. D. Assist the client into a standing position.

Correct Answer is A

Explanation

A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.

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The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

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Naxlex Comprehensive Predictor Exams

When auscultating a patient's lungs, a nurse hears an audible, high-pitched crowing sound. The nurse identifies this sound as

Correct Answer is B

Explanation

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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