A nurse is performing an eye assessment on a client and while inspecting the eyes the pupils are noted to be fixed and 7 mm in size. How should the nurse document this finding?
cataracts
miosis
astigmatism
mydriasis
The Correct Answer is D
A) Cataracts: Cataracts are a condition where the lens of the eye becomes cloudy, leading to blurred vision. While cataracts can impact vision, they do not cause fixed, dilated pupils. Cataracts would typically affect the clarity of vision rather than pupil size and response.
B) Miosis: Miosis refers to constricted pupils that are smaller than normal, typically less than 2 mm in size. The finding described in the question (fixed and 7 mm) is the opposite of miosis, which would indicate excessively small pupils.
C) Astigmatism: Astigmatism is a refractive error caused by an irregular shape of the cornea or lens, resulting in blurry vision. It is unrelated to the size or responsiveness of the pupils and does not cause fixed or dilated pupils, making it an inappropriate choice for this finding.
D) Mydriasis: Mydriasis refers to the dilation of the pupils, typically greater than 6 mm in size. When the pupils are fixed and dilated (7 mm, as described), this condition is termed mydriasis. It can occur due to various factors such as certain medications, trauma, or neurological issues. The nurse should document this finding as mydriasis and notify the healthcare provider for further assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) 2 mm: A pupil size of 2 mm would be considered small and is generally indicative of miosis, which can occur due to certain medications, increased intracranial pressure, or other factors. A size of 2 mm is not typically expected as a normal finding for pupil size in healthy individuals.
B) 6 mm: While 6 mm is within the upper normal range for pupil size, it is on the larger end. Pupils usually range from 3 mm to 6 mm in size under normal lighting conditions. However, pupils dilating to 6 mm can occur in response to low light conditions or sympathetic stimulation.
C) 8 mm: A pupil size of 8 mm would be considered dilated (mydriasis) and is abnormal under normal lighting conditions. Such a large pupil may suggest conditions like drug use, neurological issues, or other medical concerns that need to be assessed.
D) 4 mm: A pupil size of 4 mm is considered a normal and expected finding under standard lighting conditions. It falls within the typical range for adult pupil size and reflects a healthy, functional response to ambient light conditions. This size is within the commonly observed range for normal pupils.
Correct Answer is B
Explanation
A) 3+: A 3+ tonsil grading indicates that the tonsils are enlarged and occupy more than 75% of the lateral dimension of the oropharynx. The description provided in the question indicates that the tonsils occupy more than 50% but less than 75% of the space, so a 3+ grade is too large to match this description.
B) 2+: A 2+ tonsil grading indicates that the tonsils are enlarged and occupy between 50% and 75% of the lateral dimension of the oropharynx. This matches the description in the question, where the tonsils are smooth, pink, and occupy more than 50% but less than 75% of the space.
C) 1+: A 1+ tonsil grading refers to tonsils that are small and occupy less than 25% of the lateral dimension of the oropharynx. This would not be consistent with the findings described in the question, where the tonsils are larger and occupy a greater proportion of the oropharynx.
D) 4+: A 4+ tonsil grading indicates that the tonsils are extremely enlarged and occupy more than 75% of the lateral dimension of the oropharynx. This would be a much larger size than described in the question. Therefore, a 4+ grading is not appropriate here.
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