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

The eyes converge to focus on the light.

The eye focuses the image in the center of the pupil.

Dilation of both pupils occurs in response to bright light.

Constriction of both pupils occurs in response to bright light.

Answer and Explanation

The Correct Answer is D

A. The eyes converge to focus on the light.

This statement refers to the convergence reflex, where both eyes move medially (towards each other) to maintain single binocular vision when focusing on a near object. It is not related to the pupillary light reflex, which involves changes in pupil size in response to light.

B. The eye focuses the image in the center of the pupil.

This choice does not accurately describe the pupillary light reflex. The pupillary light reflex involves constriction of the pupil in response to light, not focusing an image in the center of the pupil.

C. Dilation of both pupils occurs in response to bright light.

This statement is incorrect. In response to bright light, the pupils should constrict, not dilate. Dilation of pupils in bright light could indicate an abnormal response, such as in cases of certain neurological conditions or drug use.

D. Constriction of both pupils occurs in response to bright light.

This choice is correct. In the pupillary light reflex, both pupils constrict when exposed to bright light. This response is a protective mechanism to prevent excessive light from entering the eyes, ensuring optimal visual acuity.

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Correct Answer is C

Explanation

A. Bronchovesicular breath sounds and normal in that location:

Bronchovesicular breath sounds are medium-pitched sounds heard over the major bronchi and are usually equal on inspiration and expiration. They are typically heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. While they might be normal in certain locations, hearing them over peripheral lung fields might indicate an abnormality.

B. Normally auscultated over the trachea:

This statement doesn't specify a particular type of breath sound. Tracheal breath sounds are harsh and relatively high-pitched, heard directly over the trachea. They are normal over the trachea but are not normally heard in the lung periphery.

C. Vesicular breath sounds and normal in that location:

Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration. They are longer on inspiration than expiration and are considered normal breath sounds heard in the peripheral lung fields. Hearing vesicular sounds in the posterior lower lobes is typical and indicates normal lung function.

D. Bronchial breath sounds and normal in that location:

Bronchial breath sounds are high-pitched and loud, heard primarily over the trachea and larynx. If heard in the peripheral lung fields, especially in the lower lobes, it can suggest an abnormality such as consolidation or compression of lung tissue.

A. Clear and equal breath sounds bilaterally B. Oxygen saturation of 98% on room air C. Cough producing clear, thin sputum D. Visible use of accessory muscles during inhalation

Correct Answer is D

Explanation

A. Clear and equal breath sounds bilaterally

Explanation: Clear and equal breath sounds bilaterally indicate normal lung sounds, suggesting proper air exchange in both lungs. This is a normal finding and does not require immediate reporting.

B. Oxygen saturation of 98% on room air

Explanation: An oxygen saturation level of 98% on room air indicates adequate oxygenation of the blood. This is a normal and healthy oxygen saturation level and does not require immediate reporting.

C. Cough producing clear, thin sputum

Explanation: A cough producing clear, thin sputum is indicative of a non-infected or non-inflammatory condition in the respiratory system. Clear and thin sputum is often normal, especially in the absence of other symptoms. It does not require immediate reporting unless the client has other concerning symptoms.

D. Visible use of accessory muscles during inhalation

Explanation: Visible use of accessory muscles, such as neck or intercostal muscles, during inhalation suggests that the client is working hard to breathe. This could indicate respiratory distress, potentially due to conditions like asthma, COPD (Chronic Obstructive Pulmonary Disease), or other severe lung problems. It's a concerning sign and should be reported to the healthcare practitioner promptly for further evaluation and intervention.

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A nurse documents that the 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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