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 B

Explanation

Choice A rationale:

Planning to have the client lay down for 1 hour after meals is not an appropriate intervention for a client with COPD. It may increase the risk of aspiration and worsen their breathing difficulties.

Choice C rationale:

Encouraging the client to use the upper chest for respiration is not the best approach for a client with COPD. Pursed-lip breathing helps improve oxygen exchange and decreases air trapping, which is more effective in managing COPD.

Choice D rationale:

Restricting the client's fluid intake to less than 1 Vday is not a suitable intervention for a client with COPD. Dehydration can lead to thicker mucus, making it harder to breathe

A. Turn the infant onto the right side. B. Suction the oral and nasal passages. C. Give oxygen by positive pressure. D. Stimulate the infant to cry.

Correct Answer is B

Explanation

In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.

Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airﬂow and prevent further respiratory distress in the infant.

Let's brieﬂy evaluate the other options:

a) Turn the infant onto the right side.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

c) Give oxygen by positive pressure.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

d) Stimulate the infant to cry.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway take precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airﬂow and ensure adequate ventilation for the infant.

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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?

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