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.
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Related Questions
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.
Correct Answer is C
Explanation
- An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution³.
- The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work⁴.
- The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions³⁴.
Option A is incorrect because the client’s comfort level may not reflect the optimal temperature for the
enema.
Option B is incorrect because the temperature of the enema does affect its effectiveness and safety. Option D is incorrect because the temperature is too high and can cause harm to the client.
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