The 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 involuntary blinks in the presence of bright light directed over the pupils during the eye exam.
The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.
The pupils dilate when the examiner's index finger slowly moves toward the client's nose.
The Correct Answer is A
A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.
This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.
B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.
This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.
C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.
This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.
D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.
This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A slight asymmetry in breast size can be expected: This response is accurate. It acknowledges the natural variation in breast size that many women experience. It's common for one breast to be slightly larger or shaped differently than the other. It assures the client that this asymmetry is normal and not a cause for concern.
B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about: While breastfeeding can cause temporary changes in breast size and shape, not all cases of breast asymmetry are related to breastfeeding. This statement might not cover all situations, making it less accurate.
C. A sudden uneven increase in breast size is normal in adults: This statement is not accurate. Sudden changes in breast size should always be investigated, as they can indicate underlying health issues and may not be considered normal.
D. Breasts should always be symmetric: This statement is not accurate. Perfect symmetry in breast size and shape is rare. Most women have some degree of asymmetry, which is entirely normal. It's important to reassure the client that slight differences are common and not a cause for concern.
Correct Answer is C
Explanation
A. Nystagmus in extreme superior gaze: Nystagmus is an involuntary eye movement and is not a normal finding, especially in extreme superior gaze. Nystagmus can be indicative of neurological issues and requires further evaluation.
B. Slight amount of lid lag when moving the eyes from a superior to an inferior position: Lid lag refers to a delay in the downward movement of the upper eyelid during eye movement. This can be a sign of hyperthyroidism and is not a normal finding.
C. Parallel movement of both eyes: This is the correct answer. During the diagnostic positions test, the nurse should observe parallel movement of both eyes in all directions, indicating normal extraocular muscle function and coordination.
D. Convergence of the eyes: Convergence refers to the inward movement of both eyes when focusing on a close object. While convergence is a normal phenomenon, it is not specifically assessed during the diagnostic positions test, which primarily evaluates the range of motion and coordination of the extraocular muscles.
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