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

Decrease in tear production

Unequal pupillary constriction in response to light

Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

Presence of arcus senilis observed around the cornea

Answer and Explanation

The Correct Answer is B

A. Decrease in tear production: This is a common age-related change and is not considered abnormal.

B. Unequal pupillary constriction: Correct. Unequal pupillary constriction (anisocoria) is not normal and may indicate neurological issues.

C. Loss of outer eyebrow hair: This is a normal age-related change due to decreased hair follicles.

D. Arcus senilis: This is a common finding in older adults and is typically benign, caused by lipid deposits around the cornea.

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Correct Answer is B

Explanation

A. Pretibial edema: Edema is more indicative of venous function, not arterial function.

B. Palpate pedal pulses bilaterally: Palpation of the pedal pulses is essential to assess arterial circulation in the lower extremities.

C. Allen test: This assesses arterial blood flow to the hand, not the lower extremities.

D. Homan sign: Homan sign is used (though controversial) to assess for deep vein thrombosis (DVT), which is related to venous, not arterial, function.

A. Could be indicative of change in cilia; the nurse should assess for hearing loss. B. Represents poor hygiene. C. Is probably the result of lesions from eczema in his ear. D. Is a normal finding and no further follow-up is necessary

Correct Answer is D

Explanation

A. Change in cilia: This is not the cause of dry, flaky cerumen. It would not be typical to assess hearing loss based on this observation alone.

B. Poor hygiene: Dry, flaky cerumen is not indicative of poor hygiene. Hygiene-related cerumen would more likely be wet and impacted.

C. Lesions from eczema: While eczema can affect the ear canal, the dry cerumen itself is more likely to be a normal characteristic for some individuals, particularly in people of Asian descent.

D. Normal finding: The presence of dry, flaky cerumen is normal in certain ethnic groups, including East Asians, and usually requires no follow-up.

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

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:

Correct Answer is D

Explanation

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