Which of the following would be considered an expected finding when assessing accommodation in an adult client?
Constriction of pupils and convergence of eyes bilaterally
Dilation of pupils and convergence of eyes bilaterally
Nystagmus when object is moved close to the client's nose
No change in pupil size and parallel alignment of both eyes
The Correct Answer is A
A. This is the expected response when assessing accommodation. The pupils should constrict (become smaller) and the eyes should converge (move inward) as a person focuses on a near object.
B. This response is not typical for accommodation. Convergence should occur with pupil constriction when focusing on a near object.
C. Nystagmus (a rhythmic jerking of the eyes) is not a normal finding during accommodation testing. It could indicate neurological or vestibular issues.
D. This is not a typical accommodation response. The pupils should constrict, and the eyes should converge when focusing on a near object.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the expected response when assessing accommodation. The pupils should constrict (become smaller) and the eyes should converge (move inward) as a person focuses on a near object.
B. This response is not typical for accommodation. Convergence should occur with pupil constriction when focusing on a near object.
C. Nystagmus (a rhythmic jerking of the eyes) is not a normal finding during accommodation testing. It could indicate neurological or vestibular issues.
D. This is not a typical accommodation response. The pupils should constrict, and the eyes should converge when focusing on a near object.
Correct Answer is ["A","B","F"]
Explanation
A. Skin turgor refers to the elasticity of the skin, which can be affected by various conditions, including malignancy. The nurse should assess for any skin changes near the lump to identify any unusual signs.
B. The nurse should document the precise location of the mass, noting whether it is near the nipple or in another quadrant of the breast. This will help with future imaging and assessment.
C. While the history is important, it does not fall under objective findings that the nurse would document during the physical exam.
D. This is part of the patient’s history, not a direct observation during the physical exam, so it is not included in the documentation of objective findings of the breast mass.
E. Orientation refers to the patient’s mental status and does not relate to the characteristics of the breast mass.
F. The nurse should note the consistency of the mass (e.g., hard, firm, or soft). A firm, non-tender mass is often concerning for malignancy and should be documented.
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