A nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?

The pupils constrict when the examiner's index finger slowly moves toward the client's nose

The client's peripheral vision becomes sharper the examiner shines a light over the pupils

The pupils dilate when the examiner's finger slowly moves toward the client's nose

The client involuntary blinks in the of bright light directed the pupils during the eye exam

Answer and Explanation

The Correct Answer is A

A) The pupils constrict when the examiner's index finger slowly moves toward the client's nose: This is the correct description of the process of visual accommodation. Visual accommodation refers to the ability of the eyes to focus on a near object. When the examiner's finger is moved toward the client's nose, the pupils should constrict to focus the light on the retina. This response is an indicator that the client’s eyes are properly adjusting to focus on a close object.

B) The client's peripheral vision becomes sharper when the examiner shines a light over the pupils: This is not correct, as shining a light over the pupils is related to assessing the pupillary light reflex, not visual accommodation. Visual accommodation focuses on the ability to focus on a near object, while peripheral vision is related to the ability to see objects outside of the central vision, and is not influenced by the light shining directly into the pupil.

C) The pupils dilate when the examiner's finger slowly moves toward the client's nose: This is incorrect. When assessing visual accommodation, the pupils should constrict (become smaller) as the object moves closer to the face, not dilate. Dilation of the pupils would suggest a lack of accommodation and could indicate a neurological or eye condition.

D) The client involuntarily blinks in the presence of bright light directed at the pupils during the eye exam: This describes the corneal reflex, which is a response to bright light or a foreign object approaching the eye, rather than a test of visual accommodation. This reflex is mediated by the trigeminal nerve and is unrelated to the accommodation response, which focuses on the pupil's reaction to near objects.

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Correct Answer is C

Explanation

A) S2 indicates the beginning of diastole:
While S2 does coincide with the end of systole and the beginning of diastole, this statement is not the most specific or accurate way to describe the S2 heart sound. S2 marks the closure of the semilunar valves (the aortic and pulmonic valves), which occurs at the end of systole, just before diastole begins. While it is true that the S2 sound occurs as the heart transitions from systole to diastole, the closure of the semilunar valves is the more specific cause of S2.

B) S2 coincides with the carotid artery pulse:
This statement is not accurate. S2 does not exactly coincide with the carotid pulse. The S2 sound is heard slightly after the pulse due to the time it takes for the mechanical contraction of the heart to produce the sound. The carotid pulse typically corresponds more closely with the closure of the atrioventricular (AV) valves and the beginning of systole (S1), not S2. The timing of S2 and the carotid pulse can be close, but they are not perfectly synchronized.

C) S2 is caused by the closure of the semilunar valves:
This is the correct explanation. S2 is the heart sound produced by the closure of the semilunar valves (the aortic and pulmonic valves). The closing of these valves marks the end of systole and the beginning of diastole. S2 is typically described as having two components: the A2 sound (closure of the aortic valve) and the P2 sound (closure of the pulmonic valve). In some cases, particularly during inspiration, A2 and P2 may be heard separately, producing a split S2 sound.

D) S2 is louder than an S1:
This statement is not accurate. In general, S1 is louder than S2 at the apex of the heart (the lower part of the chest). S2 is louder than S1 at the base of the heart (near the sternum), particularly over the aortic and pulmonic areas. The loudness of heart sounds varies based on the location of auscultation, but it is not universally true that S2 is always louder than S1. The intensity of each sound depends on various factors, including the position of the listener and the health of the heart valves.

A. Crackles B. Stridor C. Dyspnea D. Friction rub

Correct Answer is D

Explanation

A) Crackles: Crackles are abnormal lung sounds often associated with conditions such as pneumonia, heart failure, or pulmonary edema. They result from fluid in the airways or alveoli. However, crackles are not typically the primary finding in pleuritis, which involves inflammation of the pleura.

B) Stridor: Stridor is a high-pitched wheezing sound caused by an obstruction or narrowing of the upper airway, often seen in conditions such as croup or anaphylaxis. It is not characteristic of pleuritis, which involves inflammation of the pleura and not airway obstruction.

C) Dyspnea: Dyspnea, or difficulty breathing, is a common symptom in many respiratory conditions, including pleuritis. While pleuritis can lead to discomfort during breathing, dyspnea itself is not a sound that would be auscultated. It’s a subjective feeling that would be noted during the client’s history or verbal report, rather than an auscultatory finding.

D) Friction rub: A pleural friction rub is the most expected finding when auscultating a client with pleuritis. This sound occurs when the inflamed pleural layers rub against each other during breathing, producing a grating, scratchy sound. The nurse will typically hear this sound best on inspiration or expiration and it is the hallmark sign of pleuritis. The presence of a friction rub indicates the pleural inflammation characteristic of this condition.

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A nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?

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Explanation

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Correct Answer is D

Explanation

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