The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client is experiencing a vision problem? (Select all that apply)
As the nurse dims the lights in the room, the client’s pupils dilate.
As the nurse checks for accommodation, the pupils remain dilated.
The clients far vision acuity is 20/20 bilaterally.
The client exhibits a symmetrical pupillary light reflex response.
Correct Answer : B,E
A. Dilated pupils in response to dimmed lights are a normal response and not an indication of a
vision problem.
B. Pupils that remain dilated during an accommodation test indicate that the client may have an
issue with their autonomic nervous system and is not able to adjust their pupil size appropriately.
C. Far vision acuity of 20/20 bilaterally indicates normal vision.
D. A symmetrical pupillary light reflex response is a normal finding and not an indication of a vision
problem.
E. Frowning and squinting while reading the Snellen chart may indicate that the client is having difficulty seeing the letters clearly and may have a vision problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The nurses would teach the patient to palpate all four quadrants of the breast, including the upper outer quadrant, lower inner quadrant, and upper inner quadrant, as well as the tail of Spence, which is the extension of breast tissue into the axilla (armpit). It's important for the patient to be familiar with their own breast tissue and report any changes or abnormalities to their healthcare provider.
Correct Answer is C
Explanation
"Pain is whatever the person experiencing it says it is," to include in the orientation. This definition reflects the concept of pain as a subjective experience that cannot be directly observed or measured, but only reported by the individual experiencing it. It emphasizes the importance of believing and acknowledging the patient's report of pain, and not relying solely on objective indicators or assumptions about the cause or intensity of pain. This definition also aligns with current standards of pain assessment and management, which prioritize patient-centered care and the use of self-report measures to guide treatment decisions.
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