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. Normal finding: This is not a normal finding. Dullness in this area could indicate an enlarged liver (hepatomegaly), which requires further evaluation.

B. Enlarged liver: Dullness above the right costal margin, especially around 11 cm, is often associated with hepatomegaly. The nurse should refer the patient to a physician for further investigation.

C. Hepatomegaly: While the finding could suggest hepatomegaly, the diagnosis should be confirmed by a physician. The nurse should refer the patient for further evaluation.

D. Alcohol intake: While it is relevant to ask about alcohol intake in the context of liver health, the immediate action is to refer the patient for further examination by a physician.

A. "We need to determine the areas of tenderness before using percussion and palpation." B. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." C. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." D. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

Correct Answer is C

Explanation

A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.

B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.

C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.

D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.

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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

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