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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) At the base of the skull: The occipital lymph nodes are located at the base of the skull, just above the nape of the neck. The nurse should use a gentle circular motion to palpate the area where these lymph nodes are found. This is the correct location to assess for tenderness, swelling, or abnormalities in the occipital lymph nodes.
B) In front of the ears: The lymph nodes located in front of the ears are known as the preauricular lymph nodes. These are not the occipital lymph nodes. The preauricular nodes are assessed by palpating just in front of the ear, not at the base of the skull.
C) Under the mandible: The submandibular lymph nodes are located under the mandible (lower jaw). These nodes are not the occipital lymph nodes. The nurse would need to palpate under the jawline to assess the submandibular area.
D) Above the clavicles: The supraclavicular lymph nodes are located above the clavicles (collarbones), and they are not the occipital lymph nodes. This area is assessed separately to check for lymph node enlargement or abnormal findings.
Correct Answer is D
Explanation
A) Pupil constriction: Pupil constriction (miosis) is not a typical sign of cataracts. Cataracts usually cause blurred or cloudy vision due to the clouding of the lens. Pupil constriction may occur in other conditions, such as in response to certain medications or neurological changes, but it is not associated with cataracts.
B) Cloudiness in the iris: The iris is the colored part of the eye that controls the size of the pupil. While cataracts affect vision, they typically involve the lens rather than the iris. Cloudiness in the iris could indicate other conditions, such as inflammation or infection, but it is not a characteristic of cataracts.
C) Redness in the sclera: Redness in the sclera (the white part of the eye) is usually caused by irritation, infection, or injury, such as conjunctivitis or subconjunctival hemorrhage. It is not a typical sign of cataracts, which primarily affect the lens and do not typically cause changes to the sclera.
D) Cloudiness in the lens: Cataracts are characterized by the clouding of the lens, which can result in blurry, hazy, or diminished vision. This cloudiness is visible during an eye examination, typically as a white or grayish opacity in the lens. This is the most consistent finding with cataracts.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.