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. Shield the lips: Shielding the lips ensures the patient is not lip-reading but should not muffle the sound.

B. Whisper random numbers and letters: The whisper test involves standing behind the patient, whispering a series of numbers and letters, and asking the patient to repeat them.

C. Occlude outside noise: Asking the patient to occlude one ear may alter test results.

D. Stand approximately 4 feet away: The whisper test is typically performed from 1-2 feet behind the patient.

A. High-pitched, tinkling sounds B. Normal bowel sound C. Hypoactive bowel sounds D. Hyperactive bowel sounds

Correct Answer is C

Explanation

A. High-pitched, tinkling sounds: These may indicate bowel obstruction, not expected immediately after surgery.
B. Normal bowel sounds: Normal bowel sounds usually return gradually after surgery, but are unlikely within the first 24 hours.
C. Hypoactive bowel sounds: It is common to hear hypoactive or diminished bowel sounds in the first 24-48 hours after abdominal surgery due to postoperative ileus.
D. Hyperactive bowel sounds: These suggest increased peristalsis and are not typical immediately after surgery.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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