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 B
Explanation
A.This option is appropriate for children under the age of 3. Pulling the pinna down and back straightens the ear canal in young children, but it does not align the canal correctly in adults.
B.For an adult, the correct method to straighten the ear canal during examination is to pull the pinna (outer part of the ear) up and back. This maneuver aligns the ear canal for better visualization of the tympanic membrane (eardrum) and inner structures.
C.Pulling the pinna down and forward is incorrect for both adults and children. This action would not provide a clear view of the ear canal and could make examination difficult.
D.Pulling the pinna straight back does not fully straighten the ear canal in adults and may make the examination less effective. The correct technique is up and back for adults to fully straighten the canal and enhance visualization.
Correct Answer is B
Explanation
The nurse will document the patient's chest pains that move down her left arm as radiating pain. Radiating pain is a type of pain that starts at a specific point and spreads outwards to other areas of the body. In this case, the pain starts in the chest and moves down the left arm, which is a common symptom of cardiac or heart-related issues. Phantom pain is a type of pain that is perceived to be present in a body part that has been amputated or lost. Referred pain is pain that is felt in a different part of the body from where the actual problem is located. Somatic pain is pain that arises from the skin, muscles, bones, or connective tissues.
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