To assess a client's pupillary reaction to accommodation, what action should the nurse take?

Observe pupil size when focusing on a near object and then a far object.

Compare the shape of each of the pupils bilaterally with normal room light.

Note the speed of pupil constriction when a penlight is shined into the eye.

Determine if dilation of the pupils occurs when the room is darkened.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Observing pupil size when focusing on a near object and then a far object is correct. This choice is correct because it directly assesses the pupillary reaction to accommodation, which refers to the changes in pupil size that occur when the eyes shift focus between near and far objects. Observing the pupils while the client focuses on a near object and then a far object allows the nurse to assess how the pupils constrict (become smaller) or dilate (become larger) in response to changes in focus, providing valuable information about the client's accommodation reflex.
Choice B Reason:
Comparing the shape of each of the pupils bilaterally with normal room light is incorrect. While comparing the shape of each pupil bilaterally with normal room light is a valid assessment technique for evaluating pupillary size and symmetry, it does not specifically assess the pupillary reaction to accommodation. Therefore, this choice is not as directly relevant to assessing accommodation reflex as choice A.
Choice C Reason:
Noting the speed of pupil constriction when a penlight is shined into the eye is incorrect. This choice refers to assessing the pupillary light reflex, which involves observing the speed and extent of pupil constriction in response to a bright light stimulus. While this assessment is important for evaluating the pupillary response to light, it does not specifically assess accommodation, which involves changes in pupil size in response to changes in focus between near and far objects. Therefore, this choice is not directly relevant to assessing accommodation reflex.
Choice D Reason:
Determining if dilation of the pupils occurs when the room is darkened is incorrect. This choice involves assessing the pupillary response to changes in ambient light levels, which is known as the pupillary light reflex. While assessing pupil dilation in response to darkness is important for evaluating the pupillary response to changes in light, it does not specifically assess accommodation reflex. Therefore, this choice is not directly relevant to assessing accommodation reflex.

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Correct Answer is A

Explanation

Choice A Reason:
Standing directly in front of the client and ask about any hearing loss is appropriate because the client's behavior of ignoring questions from the nurse and speaking loudly to her son suggests a potential hearing impairment. Standing directly in front of the client allows for better visibility of facial expressions and lip movements, which can aid in communication for individuals with hearing loss. Asking about any hearing loss helps the nurse gather important information to adapt communication strategies effectively.
Choice B Reason:
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests involves conducting hearing tests using a tuning fork to assess for conductive or sensorineural hearing loss. While these tests are valuable for diagnosing hearing impairments, they are typically performed after obtaining a thorough history and initial assessment, including asking about any hearing loss. Therefore, this option is not the first action to take when communication difficulties are observed.
Choice C Reason:
Beginning to orient the client to her surroundings in the hospital room involves providing orientation to the client about her surroundings, which is important for promoting comfort and reducing anxiety, especially in a new environment like a hospital room. However, addressing potential hearing loss is the priority when the client's behavior suggests difficulty in communication. Once hearing impairment is ruled out or addressed, orientation to the surroundings can be initiated.
Choice D Reason:
Performing a mental status exam to assess the client's thought processes involves assessing the client's cognitive function and thought processes, which is important for understanding the client's overall mental status. While assessing mental status is an essential aspect of comprehensive nursing assessment, it may not directly address the observed communication difficulties related to potential hearing impairment. Therefore, addressing potential hearing loss should be the first action to ensure effective communication before proceeding with a mental status exam.

A. Macule B. Papule C. Wheal D. Vesicle E. Nodule F. Pustule

Correct Answer is ["C","D","F"]

Explanation

Choice A Reason:
Macule is incorrect. A macule is a flat, discolored spot on the skin that is less than 1 centimeter in diameter. It does not contain fluid; instead, it represents a change in the color of the skin, such as a freckle or a flat mole. Macules are not filled with fluid; they are characterized by alterations in skin pigmentation without any elevation or depression.
Choice B Reason:
Papule is incorrect. A papule is a small, raised bump on the skin that is less than 1 centimeter in diameter. Papules do not contain fluid; instead, they result from localized cellular infiltration, inflammation, or proliferation in the skin layers. Examples of papules include acne lesions and insect bites.
Choice C Reason:
Wheal is correct. A wheal is a raised area of skin that is typically reddened and accompanied by itching. It contains fluid and is often associated with allergic reactions, insect bites, or hives.
Choice D Reason:
Vesicle is correct. A vesicle is a small, fluid-filled blister that appears on the skin. It contains clear fluid and can be caused by various factors such as infection, allergic reactions, or friction.
Choice E Reason:
Nodule is incorrect. A nodule is a solid, raised bump on the skin that is larger than 1 centimeter in diameter and extends into deeper layers of the skin. Similar to papules, nodules do not contain fluid; they are composed of tissue, such as fat, fibrous tissue, or tumors. Examples of nodules include lipomas and dermatofibromas.
Choice F Reason:
Pustule is correct. A pustule is a small, pus-filled blister that appears on the skin. It contains purulent fluid (pus) and is often associated with bacterial infections such as acne or folliculitis.

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To assess a client's pupillary reaction to accommodation, what action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Correct Answer is A

Explanation

Patient Data Exhibits During the assessment, the nurse notes that the areas are filled with a fluid-like substance. Which of the following primary skin lesions contain fluid? Select all that apply.

Correct Answer is ["C","D","F"]

Explanation

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