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 C

Explanation

A. Air conduction greater than bone conduction: This is tested with the Rinne test, not the Weber test.

B. Bilateral hearing loss: This is not a normal finding in the Weber test.

C. No lateralization of vibrations: In a normal Weber test, the vibrations are heard equally in both ears, indicating no conductive or sensorineural hearing loss.

D. Unilateral hearing loss: This would be abnormal and suggest hearing impairment in one ear.

A. 3,1,2,5,4 B. 2,1,4,5,3 C. 2,1,3,4,5 D. 3,2,1,5,4

Correct Answer is C

Explanation

A. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
B. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
C. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
D. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.

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Naxlex Comprehensive Predictor Exams

A nurse performs the Weber test on a healthy adult client. The nurse would expect which of the following normal finding?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

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During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

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

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