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.

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Correct Answer is D

Explanation

The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. This is a measurable goal as it has a specific action, which is to identify five major drug side effects, and a specific time frame, which is before discharge tomorrow. The goal is also realistic and achievable within the given time frame. Option A, sitting out of bed in the chair, is not specific enough and lacks a time frame. Option B, verbalizing feelings about surgery at some point, is too vague and lacks a specific action and time frame. Option C, eating low-sodium food, is specific but lacks a time frame and may not be realistic given the client's condition.

A. Observe for signs and symptoms of respiratory distress. B. Auscultate anterior and posterior lung fields. C. Inspect the skin for pallor and cyanosis. D. Assess the shape, expansion, and symmetry of the chest. E. Observe rate, rhythm, and depth of respirations.

Correct Answer is ["A","B","C","E"]

Explanation

A.Observe for signs and symptoms of respiratory distress.

B.Auscultate anterior and posterior lung fields.

C. Inspect the skin for pallor and cyanosis.

E. Observe rate, rhythm, and depth of respirations.

When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is the best example of a measurable client goal? The clientwill:

Correct Answer is D

Explanation

A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

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