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 B
Explanation
The correct answer is choice B: Children need time to actively explore their environment. Choice A rationale:
Playpens do provide a sense of security for the child, but confining the child solely to the playpen might hinder their developmental needs. While it is essential to have a safe space for a toddler, children also require opportunities to explore and engage with their environment actively.
Choice B rationale:
The practical nurse (PN) should use this rationale when responding to the parent. Children, especially toddlers, learn and develop crucial skills through active exploration of their environment. Being confined to a playpen for extended periods may limit their opportunities for learning, hinder their physical development, and restrict social interaction, which are essential aspects of their growth.
Choice C rationale:
While playpens can provide a safe environment for a toddler when used appropriately and under supervision, keeping the child confined for the sole purpose of preventing dirtiness is not recommended. Overusing playpens can hinder a child's natural curiosity and desire to explore, potentially affecting their overall development.
Choice D rationale:
While over-concern about appearance can be harmful in some contexts, it is not directly related to the child being kept in a playpen to avoid getting dirty. The primary concern here is about providing the child with adequate opportunities for exploration, growth, and development, rather than focusing solely on appearance.
Correct Answer is A
Explanation
The correct answer is choice A: Descriptions of numbness and tingling in fingers distal to the AVF.
Choice A rationale:
Descriptions of numbness and tingling in fingers distal to the arteriovenous fistula (AVF) suggest possible nerve compression or impaired blood flow, which are concerning findings. These symptoms could indicate reduced perfusion to the distal extremities and require immediate attention to prevent further complications.
Choice B rationale:
A loud and consistent bruit auscultated at the AVF site is an expected finding and indicates adequate blood flow through the fistula. A bruit is the sound of turbulent blood flow and is commonly heard over functional AV fistulas.
Choice C rationale:
Bruising at the AVF site is a common occurrence after the creation of the fistula. It is expected due to the surgical intervention and the manipulation of blood vessels. As long as the bruising is not severe or accompanied by other concerning symptoms, it does not need immediate reporting.
Choice D rationale:
The absence of the radial pulse distal to the AVF and the presence of the ulnar pulse are normal findings in a functioning AV fistula. The AV fistula diverts blood flow away from the radial artery, leading to a diminished pulse. This is not a cause for concern as long as the ulnar pulse is present, indicating adequate perfusion to the hand.
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