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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","H","I"]
Explanation
A. Low-fat diet: This reduces the risk of arterial insufficiency, making it incorrect as a risk factor.
B. Diabetes mellitus: Diabetes is a significant risk factor due to its effects on vascular health.
C. Decreased lipid levels: Lower lipid levels reduce arterial risk, making it incorrect as a risk factor.
D. Smoking: Smoking damages blood vessels and increases arterial insufficiency risk.
E. Heavy alcohol use: Excessive alcohol consumption contributes to hypertension and cardiovascular disease.
F. Physical activity: Physical activity reduces arterial risk, making it incorrect as a risk factor.
G. Hypertension: High blood pressure increases arterial insufficiency risk.
H. Male: Males have a higher risk of developing arterial insufficiency than females.
I. Obesity: Obesity increases the risk of atherosclerosis and arterial insufficiency.
Correct Answer is D
Explanation
A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.
B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.
C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.
D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.
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