Which technique should the nurse use to assess the pupillary reaction on a client?

Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction.

Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction.

Hold a finger 6-8 inches from the bridge of the patient's nose and move finger toward the patient's nose to observe pupil's reaction.

Have the client focus on a distant object, then ask the client to look at the penlight being held about 4-6 inches from the nose and observe for pupil constriction.

Answer and Explanation

The Correct Answer is B

: Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction. This is the appropriate technique to assess pupillary reaction. The nurse should stand to the side of the patient and use a penlight or other focused light source to illuminate one pupil at a time. The light should be directed from the side of the eye, not directly in front of it, to avoid stimulating the accommodation reflex. The nurse should observe for constriction of the pupil, which should occur in response to the light. This assessment is important because changes in pupil size and reactivity can indicate neurological dysfunction or other medical conditions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Apply restraints to the hands or wrists to keep the patient in bed:Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.

B. Place a belt restraint on the client when they are sitting in a chair:Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.

C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.

D. Educate the patient on using the call light and make sure the call light is within reach.This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.

A. Feeding B. Transferring C. Bathing D. Ambulation

Correct Answer is A

Explanation

The correct answer is choice A, feeding. Aspiration is a serious risk for clients who have difficulty swallowing or have other conditions that increase the risk of food or liquid entering the airway. During feeding, the nurse should monitor the client closely for any signs of distress or difficulty swallowing. The nurse may need to modify the consistency or texture of the food or liquid or use assistive devices such as a straw or feeding tube to reduce the risk of aspiration. Additionally, the nurse may need to position the client upright and provide support as needed during feeding. While safety observations are important during all activities, feeding is the most critical activity for clients at high risk of aspiration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which technique should the nurse use to assess the pupillary reaction on a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Correct Answer is D

Explanation

For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

Correct Answer is A

Explanation

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

The nurse is teaching a post-operative client about the purpose of their surgical drain. The nurse should include in this teaching which of the following statements regarding the purpose of the Jackson-Pratt (JP) drain?

Which of the following would be falsification of health records? Select all that apply.

A patient is on a PCA pump following an abdominal surgery. The order states the client can have 0.5mg morphine every 15 minutes as needed. The client pushed the button 10 times in the past 60 minutes. How many doses did the client receive?

A patient develops food poisoning from contaminated food. The contaminated food would be an example of which part of the infectious cycle?

A resident of a long-term care facility has moderate hearing loss and is hard of hearing. When communicating with this resident, which of the following would be the best initial technique?