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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Seizure precauons are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical acvity in the brain that can cause changes in behavior, movement, sensaon, or consciousness. Seizure precauons include providing a safe environment, monitoring the client's vital signs and neurological status, administering anconvulsant medicaons, and documenng the onset, duraon, and characteriscs of any seizure acvity³.

One of the potenal complicaons of a seizure is aspiraon, which is the inhalaon of foreign material into the lungs, such as saliva, vomit, or food. Aspiraon can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiraon, the praccal nurse (PN) should ensure the ready availability of equipment to perform suconing of the trachea, which is the tube that connects the mouth and nose to the lungs. Suconing of the trachea involves inserng a catheter through the nose or mouth into the trachea and applying negave pressure to remove any secreons or debris from the airway.

Therefore, opon A is the correct answer, while opons B, C, and D are incorrect.

Opon B is incorrect because inserng a urinary catheter is not related to seizure precauons or aspiraon prevenon.

Opon C is incorrect because applying so restraints may not be necessary or appropriate for a client who requires seizure precauons, as they may interfere with the natural movements of the seizure or cause injury to the client.

Opon D is incorrect because inserng a nasogastric tube is not related to seizure precauons or aspiraon prevenon.

A. Wash the hair and skin daily with mild soap and warm water. B. Omit chocolate, carbonated drinks, and fried foods from the diet. C. Express blackheads and follow with an exfoliating scrub. D. Refer to the dermatologist for prescribed long-term therapy.

Correct Answer is D

Explanation

Acne is a common skin condition that often requires specialized treatment. While general skincare practices can help maintain healthy skin, the most appropriate recommendation for a 16-year-old client seeking treatment for acne is to refer them to a dermatologist.

Acne can have various underlying causes, and eﬀective treatment often involves a tailored approach based on the individual's specific condition. Dermatologists are medical professionals specializing in skin health and are best equipped to assess and provide appropriate treatment options for acne.

Let's brieﬂy evaluate the other options:

a) Wash the hair and skin daily with mild soap and warm water.
While maintaining good hygiene is important for overall skin health, washing the hair and skin alone may not be sufficient to address acne. Acne is a multifactorial condition that requires more comprehensive treatment beyond basic hygiene practices.

b) Omit chocolate, carbonated drinks, and fried foods from the diet.
While diet can play a role in overall skin health, there is limited scientific evidence linking specific foods to the development or worsening of acne. Restricting specific foods may not be the most eﬀective or necessary approach for treating acne. Additionally, dietary changes alone may not address the underlying causes of acne.

c) Express blackheads and follow with an exfoliating scrub.
Squeezing or expressing blackheads can potentially worsen acne and lead to skin damage or infection. It is generally not recommended to atempt self-extraction of blackheads or use aggressive exfoliating scrubs without professional guidance.

In summary, when a 16-year-old client seeks advice for acne, the most appropriate recommendation for the practical nurse (PN) is to refer the client to a dermatologist for prescribed long-term therapy.
Dermatologists have the expertise to evaluate the individual's specific condition and provide appropriate treatment options tailored to their needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who requires seizure precauons, the praccal nurse (PN) should ensure the ready availability of equipment to perform which procedure?

Correct Answer is A

Explanation

A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide?

Correct Answer is D

Explanation

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