A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

"When I shine a light into the patient's eyes, the pupils should constrict."

"It is normal for the pupils to react sluggishly to light."

"When I shine a light into the patient's eyes, the pupils should dilate

"Pupil checks should be performed with the room lights on."

Answer and Explanation

The Correct Answer is A

A.   The normal response to light in the eye is pupil constriction. This indicates that the optic and oculomotor nerves are functioning properly.
B.   While a sluggish reaction can occur in some individuals, a noticeable sluggish response could indicate neurological issues, especially in a head injury.
C.   Pupils should constrict in response to light, not dilate, unless there is a significant neurological impairment.
D.   Pupil checks should ideally be performed in dim lighting for better visibility of pupillary reactions, not with the room lights on.

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Correct Answer is A

Explanation

A. The patient should stand 20 feet away from the Snellen chart to accurately measure visual acuity, which is the standard procedure.

B. The number beside the largest print is not the correct visual acuity score; the patient must read progressively smaller lines.
C. Testing with reading glasses is appropriate only for patients who need them for close-up vision, but the Snellen test typically measures distance vision.
D. The distance should be 20 feet, not 50 feet, to ensure proper testing conditions.

A. directly below the sternum. B. the left of the sternum at the third intercostal space. C. the left midclavicular line at the fifth intercostal space D. tightly above the left nipple.

Correct Answer is C

Explanation

A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.

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A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

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Naxlex Comprehensive Predictor Exams

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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