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 A

Explanation

A. Documenting the finding is important to ensure proper record-keeping, especially in clients with dark pigmented skin, where some variations in skin tone may be normal.
B. Asking about antibiotics is unnecessary unless there's suspicion of a drug-induced reaction or side effect.
C. While use of irritating chemicals could cause changes, this scenario does not directly suggest that as the cause.
D. Referral to a dermatologist is not required without further investigation to determine if the discoloration is concerning.

A. Ask the client if he took any pain medication at home. B. Observe for nonverbal signs to measure pain intensity. C. Use a standard pain assessment questionnaire and scale. D. Collect a urine sample and strain for granules or calculi.

Correct Answer is D

Explanation

A. While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B. Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C. Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D. The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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