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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.
Correct Answer is C
Explanation
The correct answer is choice C, face. When beginning a complete bed bath, the nurse should first wash the client's face, followed by the arms, chest, abdomen, legs, perineal area, back, and then feet. Washing the face first is important to promote client comfort and hygiene, and also sets a positive tone for the rest of the bath. Additionally, washing the face before the perineal area helps to prevent cross-contamination of bacteria from the perineal area to the face.
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