When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:
dilation reflex.
brisk reflex,
accommodation.
consensual reflex
The Correct Answer is D
A. The dilation reflex refers to pupils dilating in response to dim light, not constricting.
B. A brisk reflex is an expected response, but it does not describe the bilateral pupil constriction when light is shone in one eye.
C. Accommodation refers to the process of the eyes adjusting focus for near vision, not pupil constriction in response to light.
D. Consensual reflex is when both pupils constrict in response to light shined in either one of the eyes, indicating normal neurological function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Kussmaul's respirations are rapid, deep, and labored breaths often seen in metabolic acidosis, which does not match the pattern described.
B. Cheyne-Stokes respirations are characterized by a pattern of deep and fast breathing followed by periods of apnea. This pattern is seen in patients with severe conditions like heart failure or brain injury.
C. Biot's respirations are irregular, but the cycle does not have a distinct pattern of fast, slow, and apnea periods.
D. Hyperventilation refers to an increased rate of breathing but does not involve the cycles of deep, slow, and apneic phases characteristic of Cheyne-Stokes.
Correct Answer is D
Explanation
A. Rinsing the thermometer with water is not necessary to ensure an accurate reading. The thermometer should be cleaned after use but rinsing with water does not directly ensure accuracy.
B. Using a dry cotton ball to dry the thermometer is unnecessary and could leave fibers on the device that may interfere with reading accuracy.
C. Wiping the thermometer with alcohol helps sanitize it but does not directly influence the accuracy of the reading.
D. Shaking down the galinstan alloy to below normal is necessary to reset the thermometer before use, ensuring that the mercury level is accurate when taking a new temperature.
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