The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?
Peripheral vision intact.
Nystagmus present with pupillary focus.
Consensual pupillary constriction present
Pupils reactive to accommodation
The Correct Answer is D
The correct answer is choice D, Pupils reactive to accommodation. Choice A rationale:
"Peripheral vision intact”. refers to the ability to see objects at the outer edges of one's visual field. It is not relevant to the assessment of pupillary response and does not describe the finding of pupils constricting as they change focus from a far object to a near object.
Choice B rationale:
"Nystagmus present with pupillary focus”. suggests involuntary rapid eye movements accompanied by changes in pupillary response. Nystagmus is not an expected finding during pupillary accommodation, and its presence would indicate a neurological issue rather than a normal response.
Choice C rationale:
"Consensual pupillary constriction present”. refers to both pupils constricting when light is shined into one eye. While this finding is normal, it does not specifically describe the pupils' response during accommodation when focusing from a far object to a near object.
Choice D rationale:
"Pupils reactive to accommodation”. accurately describes the normal physiological response of the pupils constricting as they change focus from a distant object to a nearby object. This response ensures that the appropriate amount of light enters the eyes to maintain clear vision during different distances of focus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B. Refer to the dermatologist for prescribed long-term therapy. Choice A rationale:
Omitting specific foods like chocolate, carbonated drinks, and fried foods from the diet is a common misconception about acne management. While a healthy diet can contribute to overall skin health, there is no direct evidence to support the notion that avoiding these foods alone will effectively treat acne. Acne is a complex skin condition influenced by various factors, including hormonal imbalances and genetics.
Choice B rationale:
Referring the client to a dermatologist for prescribed long-term therapy is the most appropriate recommendation for managing acne. Dermatologists are medical professionals specialized in skin conditions and can provide personalized treatment plans based on the client's specific type and severity of acne. They may prescribe topical or oral medications, such as retinoids, antibiotics, or hormonal therapy, to effectively manage acne.
Choice C rationale:
Expressing blackheads and using an exfoliating scrub is not a recommended approach for managing acne. Manual extraction of blackheads can lead to skin irritation, infection, and scarring. Exfoliating scrubs can also cause damage to the skin, especially if used too frequently or if the acne is inflamed.
Choice D rationale:
Washing the hair and skin daily with mild soap and warm water is a general hygiene recommendation and may help to keep the skin clean, but it is not a specific and effective treatment for acne. Acne requires targeted therapies to address its underlying causes and manage its symptoms.
Correct Answer is A
Explanation
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
B. A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
C. Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
D. Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
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