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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Wrapping the cuff snugly around the arm is important for an accurate reading. The cuff should be snug but not tight to avoid false readings.
B. Positioning the cuff bladder over the brachial artery ensures the correct placement for accurate measurement.
C. Placing the arm above the level of the heart can lead to a falsely low blood pressure reading. The arm should be at heart level for an accurate measurement.
D. Ensuring the gauge starts at zero is critical for accurate measurement and avoids errors in reading.

A. frequency B. duration C. location. D. character E. intensity

Correct Answer is ["A","B","C","D","E"]

Explanation

A. The frequency of pain is essential to understand how often the patient experiences pain.
B. Duration refers to how long the pain lasts, which is an important characteristic to document.
C. The location of pain helps determine its origin and the appropriate treatment approach.
D. The character of the pain, such as sharp, dull, or aching, aids in identifying its nature and cause.
E. The intensity of pain is crucial for assessing the effectiveness of pain management and guiding treatment decisions.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Correct Answer is C

Explanation

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

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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: