A nurse document that a client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

The eye focuses the image in the center of the pupil

Constriction both pupils occurs in response to bright light

The eye focuses the light on the sclera

Dilation of both pupils occurs in response to bright light

Answer and Explanation

The Correct Answer is B

A) The eye focuses the image in the center of the pupil:
This option describes the accommodation reflex, not the pupillary light reflex. The accommodation reflex involves the focusing of the eye to bring an image to the center of the retina, but it does not relate to the constriction of the pupils in response to light. Therefore, it is not the correct answer for describing the pupillary light reflex.

B) Constriction of both pupils occurs in response to bright light:
This is the correct description of the pupillary light reflex. When light is shined into one eye, the normal response is for both pupils (direct and consensual response) to constrict. The pupillary light reflex tests the integrity of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III), which control the constriction of the pupil in response to light. A normal pupillary light reflex is characterized by the constriction of both pupils when exposed to light.

C) The eye focuses the light on the sclera:
This statement is inaccurate. The sclera is the white part of the eye, and light is focused on the retina (specifically the fovea) for proper vision. This does not relate to the pupillary light reflex, which specifically refers to the constriction of the pupils in response to light.

D) Dilation of both pupils occurs in response to bright light:
This is incorrect. Dilation of the pupils occurs in low light conditions as part of the pupillary dilation reflex (also called the "dark reflex") to allow more light into the eye. However, in response to bright light, the pupils constrict, not dilate. The constriction of the pupils in bright light is the primary characteristic of a normal pupillary light reflex.

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Correct Answer is C

Explanation

A) Lid lag when moving the eyes from a superior to an inferior position:
This is incorrect. Lid lag refers to a delay in the movement of the eyelid as the eyes move downward. It is considered an abnormal finding and is often associated with conditions like hyperthyroidism (Graves' disease), where the eyelid does not follow the downward gaze appropriately. In the diagnostic positions test, normal eye movement should not include lid lag.

B) Nystagmus when reading the Snellen chart:
This is incorrect. Nystagmus is an involuntary, rhythmic oscillation of the eyes, which can be indicative of a neurological or vestibular issue. It is not a normal finding during the diagnostic positions test. Nystagmus may be seen with certain disorders, such as vestibular dysfunction, neurologic damage, or alcohol intoxication, but it should not occur as a normal response to eye movement during the diagnostic positions test.

C) Parallel movement of both eyes:
This is the correct answer. In a normal result of the diagnostic positions test, both eyes should move in parallel and remain aligned during all directions of gaze. The purpose of this test is to assess for any eye muscle weakness or cranial nerve dysfunction that might cause misalignment, such as strabismus or a disorder affecting the extraocular muscles. If both eyes track smoothly and simultaneously without deviation or lag, this is a normal and expected finding.

D) Convergence of the eyes:
This is incorrect. While convergence (the inward movement of both eyes toward the nose) is a normal response when focusing on a near object, it is not the specific goal of the diagnostic positions test. The diagnostic positions test is primarily concerned with assessing the ability of the eyes to move together in all directions of gaze without misalignment or abnormal movement. While convergence is a sign of normal eye function, it is not the primary focus of this particular test.

A. Tactile fremitus B. Adventitious sounds C. Friction rub D. Crepitus

Correct Answer is D

Explanation

A) Tactile fremitus:
Tactile fremitus refers to the vibrations felt on the chest wall when a patient speaks. It is assessed by placing the hands on the chest while the patient says "ninety-nine" or a similar phrase. Tactile fremitus is used to detect changes in lung density, such as consolidation or fluid. It does not describe a crackling sensation on the skin surface. A coarse, crackling sensation is more indicative of a different condition.

B) Adventitious sounds:
Adventitious sounds are abnormal lung sounds, such as crackles, wheezes, or rhonchi, heard during auscultation. These sounds are typically related to lung conditions, such as pneumonia, asthma, or fluid accumulation in the lungs. While adventitious sounds are significant findings during auscultation, they do not describe the physical sensation of crackling felt on the skin surface. Therefore, adventitious sounds are not the correct diagnosis for a tactile sensation over the chest.

C) Friction rub:
A friction rub is a harsh, grating sound heard during auscultation and is caused by inflammation of the pleura (the lining around the lungs). It occurs when the inflamed pleural surfaces rub together during breathing. While it is a distinct sound, a friction rub is not a tactile or palpable sensation. The crackling sensation described in the question is not related to the sounds produced by a pleural friction rub.

D) Crepitus:
Crepitus is the correct answer. It refers to a coarse, crackling sensation felt on the skin surface when air or gas is trapped under the skin, often due to conditions such as subcutaneous emphysema. This can occur when there is air leaking from the lungs or other parts of the respiratory system, often following trauma (e.g., rib fractures or surgery) or infection (e.g., gas gangrene). The crackling sensation felt during palpation of the chest wall is characteristic of crepitus, making this the most appropriate finding in this scenario.

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A nurse document that a client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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