What actions should a nurse implement when assessing a patient's accommodation? (Select all that apply.)
Move his or her finger slowly toward the patient's nose
Checking for a nystagmus
Assess for convergence
Observe for pupillary constriction.
Note blinking
Hold his or her finger approximately 20 inches in front of the patient's eyes.
Correct Answer : A,C,D
a) Move his or her finger slowly toward the patient's nose: This is an appropriate action for testing accommodation, as it assesses the ability of the eyes to converge and maintain focus on the object as it moves closer.
b) Checking for a nystagmus: This is not directly related to accommodation, though nystagmus can be observed in other assessments for visual and neurological conditions.
c) Assess for convergence: Convergence is part of the accommodation process. It involves the eyes turning inward to focus on a near object.
d) Observe for pupillary constriction: Pupillary constriction is a key part of the accommodation response when focusing on a near object.
e) Note blinking: This is not necessary for assessing accommodation. Blinking can occur for various reasons but is not a direct sign of accommodation.
f) Hold his or her finger approximately 20 inches in front of the patient's eyes: For accommodation testing, the object should be moved closer, typically within 6-8 inches from the eyes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a) "Use a sterile glove and applicator to apply the antibiotic ointment." Using sterile equipment is not necessary for the application of ophthalmic ointment. The key is proper hand hygiene to prevent the spread of infection.
b) "Keep your eye open for 30 sec after instilling the ointment." It is unnecessary to keep the eye open for 30 seconds after applying the ointment. It should be gently closed to help distribute the medication.
c) "Always wipe from the outer to the inner canthus when wiping away secretions." This is incorrect because wiping from the inner to the outer canthus is recommended to prevent contamination of the clean parts of the eye.
d) "Apply the ointment in a thin line into the conjunctival sac." This is the correct method for applying the ointment, ensuring that the medication reaches the affected area.
Correct Answer is B
Explanation
a) Fever: Fever is not a common adverse effect of mannitol.
b) Fluid overload: Mannitol is an osmotic diuretic, and while it helps reduce fluid in the brain, it can sometimes lead to fluid retention and overload in other parts of the body.
c) Bradycardia: Bradycardia is not a typical adverse effect of mannitol.
d) Anaphylaxis: Although rare, anaphylaxis is a potential but not common adverse effect of mannitol. It is more likely to cause fluid and electrolyte disturbances.
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