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. Consists of two lobes.
This statement is correct. The left lung consists of two lobes: the upper lobe and the lower lobe. The right lung, not the left lung, has three lobes: upper, middle, and lower lobes.
B. Primarily consists of an upper lobe on the posterior chest.
This statement is not accurate. The upper lobe of the left lung is present in the anterior and posterior parts of the chest. It is not limited to the posterior chest.
C. Is shorter than the right lung because of the underlying stomach.
This statement is not correct. The left lung is not shorter due to the underlying stomach. The left lung is slightly smaller than the right lung to accommodate the space for the heart, but this size difference is not due to the stomach.
D. Is divided by the horizontal fissure.
This statement is not accurate. The left lung is not divided by the horizontal fissure. The horizontal fissure is a feature of the right lung, not the left lung. The left lung is divided by the oblique fissure into the upper and lower lobes
Correct Answer is A
Explanation
A. Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation. They occur in individuals who are in a supine position and disappear after a few breaths. These crackles are not indicative of any pathological condition; they are common when the lungs are not fully aerated, especially when a person is lying down.
B. Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung areas. They are soft, low-pitched, and continuous throughout inspiration and part of expiration. Vesicular breath sounds are the typical sounds heard during routine breathing and are not associated with crackling or popping noises.
C. Fine wheezes:
Wheezes are high-pitched whistling sounds heard during expiration. They occur due to narrowed airways and are commonly associated with conditions like asthma or bronchoconstriction. Fine wheezes suggest a partial obstruction in the smaller airways, causing turbulent airflow, leading to the characteristic sound.
D. Fine crackles and may be a sign of pneumonia:
Fine crackles are high-pitched, discontinuous, crackling sounds heard during inspiration. They can occur due to the sudden opening of small airways, and their presence may indicate fluid in the lungs or lung inflammation. Fine crackles are often associated with conditions such as pneumonia, heart failure, or interstitial lung diseases.
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