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 A
Explanation
The correct answer is choice A. When conducting a physical assessment of the extremities, the most appropriate assessment would be to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity. This comprehensive assessment can help to identify potential issues with circulation, strength, and skin integrity, and can also provide a baseline for ongoing assessments. Rebound tenderness in both the arms and legs, skin turgor, and moisture (choice B) are not typically assessed during a physical assessment of the extremities. Assessing the measurements in centimeters of each extremity, pulses, and varicosities (choice C) may be appropriate in certain situations, but it is not a comprehensive assessment of the extremities. Assessing pulses, strength, range of motion, percussion, odor, and edema (choice D) is also not a comprehensive assessment of the extremities and may not provide a complete picture of the client's condition. Therefore, the most appropriate assessment when conducting a physical assessment of the extremities is to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity.
Correct Answer is B
Explanation
The correct answer is choice B, Use water and mild soap.
When teaching a patient about ostomy care, the nurse should instruct the patient to clean the area around the ostomy with water and mild soap. Using a whirlpool bath, alcohol-based sanitizer, or chlorhexidine or HCG is not recommended as they can irritate the skin and damage the stoma. Cleansing the ostomy area with water and mild soap is the best way to maintain the skin's integrity and prevent irritation and infection.
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