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 C
Explanation
"I realize that my life must go on, but sometimes I wonder why.”
Choice A rationale:
This statement may indicate frustration with physical limitations, which is common in older adults, especially after surgery. It does not necessarily indicate a need for bereavement counseling.
Choice B rationale:
Difficulty remembering simple things can be attributed to normal aging processes or other factors not directly related to bereavement.
Choice C rationale:
Expressing a sense of wondering "why”. after the loss of a spouse suggests ongoing grief and a potential need for bereavement counseling to process feelings and find meaning in life after the loss.
Choice D rationale:
Depending on children who live close-by is a common support mechanism for older adults and does not directly indicate a need for bereavement counseling.
Correct Answer is B
Explanation
The PN should not prioritize bringing a glucometer to the room in this situation. The client's unresponsiveness indicates a potential medical emergency that requires immediate action, and checking blood glucose levels is not the primary concern at this moment.
Choice C rationale:
Feeling for a carotid pulse is an essential step in assessing the client's circulation. However, it is not the first priority when the client is unresponsive. The PN should focus on obtaining emergency help first to ensure timely intervention.
Choice D rationale:
Checking the blood pressure can provide valuable information about the client's condition, but it is not the most critical step when dealing with an unresponsive client. Promptly seeking emergency assistance is more important to address the immediate concern.
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