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 D
Explanation
The correct answer is D. Electrolytes.
Choice A rationale: The white blood cell count (WBC) is typically reviewed for signs of infection or inflammation, but it is not directly related to numbness and tingling.
Choice B rationale: Hematocrit levels assess the proportion of red blood cells in the blood, which are not commonly associated with numbness and tingling.
Choice C rationale: Albumin and protein levels are important for nutritional status and overall health but are not directly associated with numbness and tingling.
Choice D rationale: Electrolytes are crucial for nerve function and muscle contractions. Abnormal levels of electrolytes (such as calcium, potassium, or sodium) can lead to symptoms like numbness and tingling in the extremities.
Correct Answer is ["A","B","D"]
Explanation
These are the correct supplies for the PN to gather because they are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site and secure it with paper tape after removing the saline lock.
C. A three mL syringe is not needed to remove a saline lock and may cause confusion or harm if used incorrectly.
E. Sterile gloves are not needed to remove a saline lock and may be wasteful or unnecessary.
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