The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client is experiencing a vision problem? (Select all that apply)
As the nurse dims the lights in the room, the client’s pupils dilate.
As the nurse checks for accommodation, the pupils remain dilated.
The clients far vision acuity is 20/20 bilaterally.
The client exhibits a symmetrical pupillary light reflex response.
Correct Answer : B,E
A. Dilated pupils in response to dimmed lights are a normal response and not an indication of a
vision problem.
B. Pupils that remain dilated during an accommodation test indicate that the client may have an
issue with their autonomic nervous system and is not able to adjust their pupil size appropriately.
C. Far vision acuity of 20/20 bilaterally indicates normal vision.
D. A symmetrical pupillary light reflex response is a normal finding and not an indication of a vision
problem.
E. Frowning and squinting while reading the Snellen chart may indicate that the client is having difficulty seeing the letters clearly and may have a vision problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse would describe this as tinnitus, which is a sensation of hearing sound when no external sound is present. Tinnitus is commonly described as ringing in the ears, but can also be perceived as buzzing, humming, hissing, or other sounds. Tinnitus can be caused by a variety of factors, including age-related hearing loss, exposure to loud noises, ear infections, certain medications, and underlying medical conditions such as high blood pressure, thyroid disorders, or head and neck injuries. It is important for the patient to see a healthcare provider to determine the underlying cause and appropriate treatment.
Correct Answer is ["A"]
Explanation
To map the client's abdomen into four quadrants, the nurse should use the umbilicus as the landmark to perform this assessment. The abdomen is divided into four quadrants by drawing an imaginary line from the center of the umbilicus to the pubic symphysis and another line from the center of the umbilicus to the xiphoid process of the sternum. This helps in identifying the location of any potential abdominal discomfort or tenderness.
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