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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Gathering information from a family member can help obtain a more accurate history, especially when the patient has difficulty recalling specific details due to age-related memory changes.
B. Omitting the interview would lead to incomplete information and potentially delay appropriate care.
C. Repeating the questions may be helpful but may not always yield reliable data if the patient struggles to remember key details.
D. While forgetfulness can be normal with aging, healthcare providers need to ensure accurate information is collected to provide optimal care.

A. directly below the sternum. B. the left of the sternum at the third intercostal space. C. the left midclavicular line at the fifth intercostal space D. tightly above the left nipple.

Correct Answer is C

Explanation

A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

Correct Answer is A

Explanation

The nurse taking an apical pulse would place the stethoscope at:

Correct Answer is C

Explanation

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