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 D

Explanation

A. A hematoma refers to a collection of blood outside of blood vessels, typically resulting in a bruise or swelling. The description of round, flat, pinpoint red spots does not suggest this type of injury.
B. Vesicles are small fluid-filled blisters, which do not match the description of the pinpoint red spots. Vesicles would be more elevated and contain fluid.
C. Ecchymosis refers to a bruise, or large, irregular areas of discoloration caused by blood leaking into the tissues. The description of pinpoint red spots suggests petechiae, not ecchymosis.
D. Petechiae are small, round, flat, pinpoint red or purple spots that occur when small blood vessels (capillaries) break under the skin. This is the most appropriate description for the observed finding, particularly in the context of trauma from intimate partner violence.

A. Screen client for alcohol or controlled drug abuse. B. Evaluate client for side effects of routine medications. C. Instruct client to demonstrate activities of daily living. D. Focus questions to evaluate long term memory.

Correct Answer is C

Explanation

A. Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B. Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C. Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D. Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.

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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 is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is D

Explanation

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Correct Answer is C

Explanation

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?

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

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?

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The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.