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 B

Explanation

A) The third heart sound (S3): The third heart sound (S3) occurs early in diastole, immediately following S2. It is often associated with conditions that cause increased volume and pressure in the ventricles, such as heart failure or dilated cardiomyopathy. S3 is not heard late in diastole, so it does not match the described timing of the extra heart sound.

B) The fourth heart sound (S4): The fourth heart sound (S4) is heard late in diastole, just before S1. It is caused by the atria contracting forcefully to push blood into a non-compliant or stiff ventricle, often associated with conditions like left ventricular hypertrophy or ischemic heart disease. The timing of S4, occurring just before S1, makes it the correct identification of the described extra heart sound.

C) A split second heart sound S2: A split S2 occurs when the aortic and pulmonic valves do not close simultaneously, causing the second heart sound (S2) to be heard as two distinct components. This split can vary with respiration but does not occur late in diastole. Therefore, it does not align with the extra heart sound heard just before S1.

D) A friction rub: A friction rub is a sound associated with pericarditis, caused by the rubbing of inflamed pericardial layers. It has a distinct, grating quality and can be heard throughout the cardiac cycle. A friction rub is not a late diastolic sound, making it an incorrect identification for the extra heart sound described.

A. Simultaneously palpating both arteries to compare amplitude B. Auscultating the artery at the base of the neck at the carotid bifurcation C. Listening with the diaphragm of the stethoscope to assess for bruits D. Instructing the client to take deep breaths during auscultation

Correct Answer is B

Explanation

A) Simultaneously palpating both arteries to compare amplitude: Palpating both carotid arteries simultaneously is contraindicated as it can obstruct blood flow to the brain, potentially causing a decrease in cerebral perfusion and leading to syncope or other complications. Each artery should be palpated one at a time to prevent this risk.

B) Auscultating the artery at the base of the neck at the carotid bifurcation: The correct technique for assessing for carotid artery blockage is to auscultate the artery at the carotid bifurcation, which is located at the base of the neck. The nurse should use the bell of the stethoscope to listen for bruits, which are abnormal sounds caused by turbulent blood flow due to narrowing or blockage of the artery. This is a non-invasive method used to detect vascular abnormalities.

C) Listening with the diaphragm of the stethoscope to assess for bruits: The diaphragm of the stethoscope is generally used for high-pitched sounds like lung and bowel sounds. For auscultating bruits, the bell of the stethoscope is preferred because it is more sensitive to low-pitched sounds, which are characteristic of bruits caused by turbulent blood flow in narrowed arteries.

D) Instructing the client to take deep breaths during auscultation: Instructing the client to take deep breaths is unnecessary and could alter the sound being auscultated. The nurse should have the client breathe normally to avoid interference with the auscultation of the carotid arteries. The goal is to listen for any abnormal sounds (bruits) without any external factors affecting the findings.

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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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