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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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.

A. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency B. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D. Hormonal changes causing vasodilation and a resulting drop in blood pressure

Correct Answer is C

Explanation

A. Atrophy of calf veins: Vein atrophy is not a normal aging process, although venous insufficiency is common due to other causes.

B. Narrowing of the inferior vena cava: This is not a typical age-related change.

C. Peripheral blood vessels growing more rigid: Arteriosclerosis (hardening of the arteries) is common with aging and leads to increased systolic blood pressure.

D. Hormonal changes causing vasodilation: Aging tends to cause vascular rigidity, not vasodilation, and is more likely to lead to hypertension.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

Correct Answer is C

Explanation

The nurse is testing a patient's visual accommodation, which refers to which action?

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed?

When assessing the abdomen most health care providers divide the abdomen into how many sections?

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

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