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.
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Related Questions
Correct Answer is A
Explanation
a) A red, dull, thick, and immobile tympanic membrane: In acute otitis media, the tympanic membrane typically appears red, dull, thickened, and may be immobile due to fluid and infection in the middle ear.
b) A transparent and clear tympanic membrane: This would suggest a healthy, non-infected ear, which is not expected in acute otitis media.
c) A pink-colored tympanic membrane: This is not a typical finding in acute otitis media; a pink membrane is more characteristic of a healthy ear.
d) A pearly colored tympanic membrane: A pearly color is normal for the tympanic membrane, indicating a healthy ear with no infection.
Correct Answer is C
Explanation
a) Has no serious complications: Bacterial pharyngitis, especially streptococcal pharyngitis, can have serious complications, such as rheumatic fever or glomerulonephritis, which are not seen with viral pharyngitis.
b) Presents a negative culture: Bacterial pharyngitis typically presents with a positive throat culture for bacteria, while viral pharyngitis typically shows a negative culture.
c) Has an abrupt onset: Bacterial pharyngitis often has a sudden and severe onset of symptoms, while viral pharyngitis tends to have a more gradual onset.
d) Presents a normal complete blood count (CBC): In bacterial pharyngitis, the CBC may show an elevated white blood cell count, while in viral pharyngitis, the CBC may remain normal or slightly elevated.
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