The nurse in the family practice clinic is educating a newly graduated nurse on how to correctly use a penlight. The nurse creates the expected outcome: After the review session, the newly graduated nurse will verbalize appropriate penlight examination techniques.

For each statement below, click to specify whether it indicates the outcome was met or not met.

I will confirm the patient's pupil size with the scale on the side of the penlight.

When putting the penlight at the bridge of the nose, the eyes converge and constrict

I will check the patient's pupillary reflex by shining a light into their eyes.

When shining the penlight into the patient's eyes, their pupils should dilate

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

New Nurse Statement	Met	Not Met
I will confirm the patient's pupil size with the scale on the side of the penlight.	✅
When putting the penlight at the bridge of the nose, the eyes converge and constrict	✅
I will check the patient's pupillary reflex by shining a light into their eyes.	✅
When shining the penlight into the patient's eyes, their pupils should dilate		✅

Rationale:

"I will confirm the patient's pupil size with the scale on the side of the penlight" (Met):

This is a correct use of the penlight to assess pupil size and document findings accurately.

"When putting the penlight at the bridge of the nose, the eyes converge and constrict" (Met):

This statement describes the normal accommodation reflex, where the eyes converge and pupils constrict when focusing on a near object.

"I will check the patient's pupillary reflex by shining a light into their eyes" (Met):

This correctly describes testing for the pupillary light reflex, where the pupil constricts in response to light.

"When shining the penlight into the patient's eyes, their pupils should dilate" (Not Met):

This is incorrect. The pupils should constrict in response to light, not dilate. Dilation occurs in response to low light or sympathetic stimulation.

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Correct Answer is A

Explanation

A. Rosenbaum card: Holding reading material at approximately 18 inches from the face suggests that the client has near vision sufficient to perform well on a Rosenbaum test, which evaluates near visual acuity.

B. Stroke: Difficulty reading instructions is not necessarily indicative of a stroke.

C. Visual acuity: While they may not need immediate testing, their near vision appears adequate.

D. Understands procedure: While reading aloud may indicate comprehension, the focus here is on their visual ability.

A. Stops any movement, and appears to listen for the sound B. Consider this a normal finding. C. Shows no obvious response to the noise. D. Shows a startle and acoustic blink reflex.

Correct Answer is B

Explanation

A. Stops any movement, and appears to listen for the sound: This does not relate to the corneal light reflex test.

B. Consider this a normal finding: Symmetric light reflection at the same clock position in both eyes indicates normal alignment of the eyes.

C. Shows no obvious response to the noise: This response is unrelated to the corneal light reflex test.

D. Shows a startle and acoustic blink reflex: This describes a normal response to a loud noise, not the corneal light reflex test.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse gave a client an instruction sheet for a colonoscopy. The client held the instructions approximately 18 inches from their face and read the description of the procedure aloud. The nurse recognizes that the client

Correct Answer is A

Explanation

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

Correct Answer is B

Explanation

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Which of the following is the first important step in helping the patient to relax for the complete abdominal examination?

Which of the following should the nurse perform to assess the arterial function of the lower extremities?

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

When assessing the pupillary light reflex or PERRL (pupils, round, reactive to light), the nurse should use which technique?