When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:
dilation reflex.
brisk reflex,
accommodation.
consensual reflex
The Correct Answer is D
A. The dilation reflex refers to pupils dilating in response to dim light, not constricting.
B. A brisk reflex is an expected response, but it does not describe the bilateral pupil constriction when light is shone in one eye.
C. Accommodation refers to the process of the eyes adjusting focus for near vision, not pupil constriction in response to light.
D. Consensual reflex is when both pupils constrict in response to light shined in either one of the eyes, indicating normal neurological function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.
C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.
Correct Answer is B
Explanation
A. Bradycardia is defined as a heart rate lower than 60 beats per minute. Therefore, 62 beats per minute is not bradycardic.
B. 59 beats per minute would be considered bradycardic, as it is below 60.
C. 64 beats per minute is within normal limits.
D. 60 beats per minute is on the threshold of bradycardia but typically is still within normal limits for some individuals.
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