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?

Consensual pupillary constriction present.

Nystagmus present with pupillary focus.

Pupils reactive to accommodation.

Peripheral vision intact.

Answer and Explanation

The Correct Answer is C

Accommodation refers to the ability of the eyes to adjust and focus on objects at diﬀerent distances. When a client's pupils constrict as they change focus from a far object to a near object, it indicates that their pupils are reacting appropriately to accommodate the change in focus.

To document this finding accurately, the practical nurse (PN) should document "Pupils reactive to accommodation." This statement captures the observation that the pupils are constricting in response to the client changing their focus from a far object to a near object. It indicates normal pupillary response and accommodation.

Let's brieﬂy evaluate the other options:

a) Consensual pupillary constriction present.

Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.

Therefore, it is not the appropriate documentation for the given scenario.

b) Nystagmus present with pupillary focus.

Nystagmus refers to involuntary eye movements that can aﬀect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.

d) Peripheral vision intact.

Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation. Therefore, it is not the appropriate documentation for the given scenario.

In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.

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Correct Answer is C

Explanation

Choice A reason: Completing a survey of the various ethnicities represented in the nurse's community is a good way to learn about the diversity of the population, but it is not the first step in developing cultural competencE. The nurse should first examine their own cultural background and biases before learning about others.

Choice B reason: Studying the beliefs and traditions of persons living in other cultures is a valuable way to gain knowledge and understanding of different worldviews, but it is not the first step in developing cultural competencE. The nurse should first be aware of their own cultural values and assumptions before exploring those of others.

Choice C reason: Considering how the nurse's own personal beliefs and decisions are reflective of their culture is the first step in developing cultural competencE. The nurse should recognize that their culture influences their perception, communication, and behavior, and that they may have prejudices or stereotypes that affect their interactions with clients from different cultures.

Choice D reason: Inviting a family from another culture to join the nurse for an event is a nice gesture to show respect and interest in other cultures, but it is not the first step in developing cultural competencE. The nurse should first develop self-awareness and sensitivity to their own cultural identity before engaging with others.

A. Deliver a clean voided urine specimen to the laboratory. B. Feed a client who has bilateral casts due to upper arm fractures. C. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. D. Obtain an extra box of tissues for a client who is concerned about running out of them.

Correct Answer is C

Explanation

Choice A reason: Delivering a clean voided urine specimen to the laboratory is not the first task that the AP should complete because it is not urgent or time-sensitivE. The specimen can be stored in a refrigerator or on ice until it is delivereD.

Choice B reason: Feeding a client who has bilateral casts due to upper arm fractures is not the first task that the AP should complete because it is not critical or life-threateninG. The client can wait until after breakfast to receive assistance with feedinG.

Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast is the first task that the AP should complete because it is essential and priority. The client needs to have their blood glucose level checked before receiving insulin to prevent hypoglycemia or hyperglycemiA.

Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is not the first task that the AP should complete because it is not important or necessary. The client can use other alternatives such as paper towels or napkins until they get more tissues.

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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?

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