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?
Consensual pupillary constriction present.
Nystagmus present with pupillary focus.
Pupils reactive to accommodation.
Peripheral vision intact.
The Correct Answer is C
Accommodation refers to the ability of the eyes to adjust and focus on objects at different distances. When a client's pupils constrict as they change focus from a far object to a near object, it indicates that their pupils are reacting appropriately to accommodate the change in focus.
To document this finding accurately, the practical nurse (PN) should document "Pupils reactive to accommodation." This statement captures the observation that the pupils are constricting in response to the client changing their focus from a far object to a near object. It indicates normal pupillary response and accommodation.
Let's briefly evaluate the other options:
a) Consensual pupillary constriction present.
Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.
Therefore, it is not the appropriate documentation for the given scenario.
b) Nystagmus present with pupillary focus.
Nystagmus refers to involuntary eye movements that can affect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.
d) Peripheral vision intact.
Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation. Therefore, it is not the appropriate documentation for the given scenario.
In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Developing a survey on teen pregnancies is not an appropriate action by the nurse because it does not address the issue of influenza A outbreak in the school, which can affect students of any age or gender.
Choice B reason: Holding a focus group to discuss immunizations is an appropriate action by the nurse because it can educate and inform parents and students about the benefits and risks of influenza vaccination, as well as encourage them to get vaccinated before or during flu season.
Choice C reason: Running a mandatory flu clinic is not an appropriate action by the nurse because it can violate the rights and autonomy of parents and students who may have medical or personal reasons for refusing influenza vaccination, as well as create resentment and resistance among them.
Choice D reason: Closing the school for 6 weeks is not an appropriate action by the nurse because it can disrupt the education and socialization of students, as well as cause economic and logistic problems for parents and teachers. The recommended duration of school closure for influenza A outbreak is 5 to 7 days, which is the typical incubation period of the virus.
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is the priority intervention for the client because it can detect changes in the client's condition, such as increased intracranial pressure, bleeding, or infection, that require immediate action.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not the priority intervention for the client because it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumoniA. The client should be positioned with the head of the bed elevated at 30 degrees to reduce intracranial pressure and facilitate drainagE.
Choice C reason: Administering anticoagulant medications as prescribed is not the priority intervention for the client because it can worsen the bleeding and increase the risk of hemorrhagic transformation. Anticoagulants are contraindicated for clients who have hemorrhagic stroke, which is caused by rupture of a blood vessel in the brain.
Choice D reason: Assisting the client with active range of motion exercises is not the priority intervention for the client because it can cause fatigue, pain, or injury to the affected limbs. The client should be assisted with passive range of motion exercises to prevent contractures and maintain joint mobility.
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