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: "Repeat dose in 1 hour for unrelieved headachE." This instruction is incorrect because sumatriptan should not be taken more than twice in 24 hours.

Choice B reason: "Chew tablet well before swallowinG." This instruction is unnecessary because sumatriptan tablets are meant to be swallowed whole with water.

Choice C reason: "If you experience chest pain, call your physician immediately." This instruction is important because sumatriptan can cause coronary vasospasm, which can lead to angina or myocardial infarction.

Choice D reason: "Take daily to prevent headaches." This instruction is inappropriate because sumatriptan is used to treat acute migraine attacks, not to prevent them.

A. Document that the client has expressed concerns about the surgery B. Encourage the client to continue with the scheduled surger C. Remind the client that the consent has already been obtained D. Notify the charge nurse of the client's concerns about surgery

Correct Answer is D

Explanation

d) Notify the charge nurse of the client's concerns about surgery.

Explanation:

When a client expresses fear and uncertainty about undergoing surgery, it is important for the practical nurse (PN) to communicate this information to the charge nurse or the healthcare provider. By notifying the appropriate person, the PN ensures that the client's concerns are addressed and appropriate interventions can be implemented.

Options a) and c) are not the priority actions because documenting the client's concerns or reminding them about the signed consent does not address their emotional needs or provide support.

Option b) may not be the most appropriate response, as simply encouraging the client to continue with the scheduled surgery without addressing their fears and uncertainties may not be sufficient to alleviate their anxiety.

Therefore, the best course of action is to notify the charge nurse or healthcare provider so that they can assess the client's concerns, provide reassurance, and address any questions or fears the client may have prior to the surgery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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