The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

Anisocoria of the patient's pupils.

Patient's accommodation response.

Direct pupil response of the patient.

Patient's consensual reflex.

Answer and Explanation

The Correct Answer is B

A: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.

B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B. Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C. A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or

standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D. The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E. A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.

A. Bradycardia B. Hypoglycemia C. Decreased respiratory rate D. Hypertension

Correct Answer is D

Explanation

A: Bradycardia is typically not associated with acute pain; instead, pain usually triggers a sympathetic response, leading to tachycardia.
B: Hypoglycemia has no direct correlation with acute pain levels.

C: Pain tends to increase, not decrease, the respiratory rate due to stress and increased metabolic demand.
D: Acute pain can lead to elevated blood pressure as part of the body's stress response, which includes activation of the sympathetic nervous system.

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The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

When performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that

While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that

The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?

A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

When auscultating a patient's lungs, a nurse hears an audible, high-pitched crowing sound. The nurse identifies this sound as

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the