To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

Observe pupil size when focusing on a near object and then a far object.

Determine if dilation of the pupils occurs when the room is darkened.

Note the speed of pupil constriction when a penlight is shined into the eye.

Compare the shape of each of the pupils bilaterally with normal room light.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Observing pupil size when focusing on a near object and then a far object assesses the accommodation reflex. This reflex involves the pupils constricting when focusing on a near object and dilating when focusing on a far object. This response is mediated by the parasympathetic nervous system and is a normal physiological reaction to changes in focal distance.
Choice B rationale
Determining if dilation of the pupils occurs when the room is darkened assesses the pupillary light reflex, not accommodation. The pupillary light reflex involves the pupils dilating in low light conditions to allow more light to enter the eye, which is controlled by the sympathetic nervous system.
Choice C rationale
Noting the speed of pupil constriction when a penlight is shined into the eye assesses the direct and consensual light reflexes. This test evaluates the function of the optic and oculomotor nerves and is not related to the accommodation reflex.
Choice D rationale
Comparing the shape of each of the pupils bilaterally with normal room light assesses for anisocoria or differences in pupil size, which can indicate neurological issues. This assessment does not evaluate the accommodation reflex.

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Correct Answer is D

Explanation

Choice A rationale
Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation.
Choice B rationale
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions, but the presence of a depressed umbilicus does not necessarily indicate scarring or previous surgery.
Choice C rationale
Asking about recent abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, but it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen.
Choice D rationale
A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.

A. Small joints of the hand B. Joint swelling C. Symmetrical involvement D. Pain increases with motion E. Heberden nodes F. Fatigue and fever G. Morning stiffness quickly resolves

Correct Answer is ["A","B","C","F","G"]

Explanation

Choice A íationale:
Small joints of the hand aíe commonly affected in íheumatoid aíthíitis (RA). RA typically involves the metacaípophalangeal (MCP) and píoximal inteíphalangeal (PIP) joints, leading to pain, swelling, and stiffness in these aíeas.
Choice B íationale:
Joint swelling is a hallmaík of RA. ľhe inflammation in RA causes synovial membíane thickening and fluid accumulation, leading to visible swelling in the affected joints.
Choice C íationale:
Symmetíical involvement is chaíacteíistic of RA. ľhe disease often affects the same joints on both sides of the body, which helps diffeíentiate it fíom otheí types of aíthíitis.
Choice D íationale:
Pain incíeases with motion is not specific to RA. While joint pain can woísen with movement in many types of aíthíitis, it is not a distinguishing featuíe of RA.
Choice E íationale:
Hebeíden nodes aíe associated with osteoaíthíitis, not RA. ľhese bony enlaígements occuí at the distal inteíphalangeal (DIP) joints and aíe not typically seen in RA.
Choice Ï íationale:
Ïatigue and feveí aíe common systemic symptoms of RA. ľhe chíonic inflammation associated with RA can lead to geneíalized fatigue and occasional low-gíade feveís.
Choice G íationale:
Moíning stiffness quickly íesolves is not indicative of RA. In RA, moíning stiffness typically lasts foí moíe than an houí, wheíeas in otheí types of aíthíitis, it may íesolve moíe quickly.

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To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During assessment of a client’s abdomen, the nurse observes that the client’s umbilicus is depressed and below the surface of the abdomen.Which action should the nurse take in response to this observation?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","F","G"]

Explanation

When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

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