While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

The right pupil constricts and the left consensually responds.

Both pupils are equal in size and constrict readily to the light source.

Bilateral pupil size changes as the distance of the light source varies.

The left iris is "notched" and the pupil size changes minimally.

Answer and Explanation

The Correct Answer is D

A.   This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B.   This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C.   Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D.   This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

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Correct Answer is B

Explanation

A. Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B. A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C. A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D. While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.

A. "Count backwards by 7, starting with 100." B. "What does, "The early bird catches the worm," mean?" C. "Has anyone come to visit you today?" D. "In what year were you born?"

Correct Answer is B

Explanation

A. This tests the client’s ability to perform mathematical tasks but does not specifically assess abstract
thinking. It is more of a concrete cognitive task.

B. This question assesses abstract thinking because it requires the client to interpret a proverb, which involves understanding symbolic meaning beyond the literal words.
C. This question is assessing more of the client’s orientation and memory rather than abstract thinking. It does not test higher-level cognitive abilities.
D. This is an orientation question, assessing the client’s ability to recall personal facts, but it does not
assess abstract reasoning skills.

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While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Correct Answer is B

Explanation

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

Correct Answer is B

Explanation

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