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 C
Explanation
Choice A reason: A negative-pressure isolation room is not appropriate for this client because it is used for clients who have airborne infections that can spread through small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. Scabies is a skin infection that is spread by direct contact with infested skin or clothinG.
Choice B reason: A positive-pressure isolation room is not appropriate for this client because it is used for clients who have compromised immune systems and need protection from environmental contaminants, such as bone marrow transplant recipients, burn victims, or organ transplant recipients. Scabies is not caused by environmental contaminants, but by parasitic mites that burrow under the skin.
Choice C reason: A private room is appropriate for this client because it prevents contact transmission of scabies to other clients or stafF. The client should also have dedicated equipment and linens, and wear gloves and gown when leaving the room. The room should be thoroughly cleaned and disinfected after the client's dischargE.
Choice D reason: A semi-private room with a client who has pediculosis capitis is not appropriate for this client because it increases the risk of cross-contamination between the two clients. Pediculosis capitis is a head lice infestation that can also be spread by direct contact with infested hair or personal items.
Correct Answer is A
Explanation
Choice A reason: Planning medication doses to occur before meals is a good suggestion to improve this client's nutritional status because it can enhance the client's muscle strength and coordination for chewing and swallowing, which are often impaired by myasthenia gravis.
Choice B reason: Restricting drinking fluids before and during meals is not a good suggestion to improve this client's nutritional status because it can increase the risk of dehydration and constipation, which can worsen the client's condition and appetitE.
Choice C reason: Increasing the amount of fat and carbohydrates in meals is not a good suggestion to improve this client's nutritional status because it can lead to weight gain, hyperglycemia, and cardiovascular problems, which can complicate the management of myasthenia gravis.
Choice D reason: Eating three large meals per day is not a good suggestion to improve this client's nutritional status because it can cause fatigue, bloating, and aspiration, which can affect the client's ability and willingness to eat. The client should eat small, frequent meals that are easy to chew and swallow.
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