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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Correct Answer is C

Explanation

A: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.

B: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.
C: Palpating the posterior tibialis pulse is a logical next step for checking lower extremity circulation, particularly when dorsalis pedis is not palpable, helping localize the evaluation of blood flow in the foot and ankle.
D: The femoral pulse is useful for broader leg circulation issues. However, it is less targeted than posterior tibialis for checking blood flow in the lower extremities.

A. Request assistance from a second nurse. B. Count the client's apical pulse. C. Check the client's pulse rate for 1 min. D. Calculate the difference between the client's peripheral pulse and the client's apical pulse.

Correct Answer is A

Explanation

A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.

C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is unable to palpate a client's dorsalis pedis pulse. The nurse will next attempt to palpate the

Correct Answer is C

Explanation

A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take first?

Correct Answer is A

Explanation

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