The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?
Peripheral vision intact.
Nystagmus present with pupillary focus.
Consensual pupillary constriction present
Pupils reactive to accommodation
The Correct Answer is D
The correct answer is choice D, Pupils reactive to accommodation. Choice A rationale:
"Peripheral vision intact”. refers to the ability to see objects at the outer edges of one's visual field. It is not relevant to the assessment of pupillary response and does not describe the finding of pupils constricting as they change focus from a far object to a near object.
Choice B rationale:
"Nystagmus present with pupillary focus”. suggests involuntary rapid eye movements accompanied by changes in pupillary response. Nystagmus is not an expected finding during pupillary accommodation, and its presence would indicate a neurological issue rather than a normal response.
Choice C rationale:
"Consensual pupillary constriction present”. refers to both pupils constricting when light is shined into one eye. While this finding is normal, it does not specifically describe the pupils' response during accommodation when focusing from a far object to a near object.
Choice D rationale:
"Pupils reactive to accommodation”. accurately describes the normal physiological response of the pupils constricting as they change focus from a distant object to a nearby object. This response ensures that the appropriate amount of light enters the eyes to maintain clear vision during different distances of focus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.”.
Choice A rationale:
This response shows empathy and understanding, acknowledging the client's feelings and respecting her decision not to look at or discuss the incision. It allows the client to take control of her own emotions and healing process, while also reassuring her that the nurse will be available whenever she feels ready to talk or see the incision.
Choice B rationale:
Telling the client that she will feel better when she sees the incision minimizes her feelings and may be seen as dismissive. It does not address her emotions or concerns and can be counterproductive to building trust and rapport.
Choice C rationale:
Suggesting to call another nurse to be present while showing the wound might make the client feel uncomfortable or pressured. It is essential to establish a therapeutic nurse-client relationship, and forcing the issue could increase the client's distress.
Choice D rationale:
Telling the client that part of recovery is accepting her new body image and needing to look at her incision is insensitive and inappropriate. It is not the nurse's role to dictate how the client should feel about her body or her healing process. Such a response could potentially harm the nurse-client relationship and hinder the client's emotional healing.
Correct Answer is B
Explanation
Choice A rationale:
While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.
Choice C rationale:
Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.
Choice D rationale:
Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.
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