Which technique should the nurse use to assess the pupillary reaction on a client?

Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction.

Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction.

Hold a finger 6-8 inches from the bridge of the patient's nose and move finger toward the patient's nose to observe pupil's reaction.

Have the client focus on a distant object, then ask the client to look at the penlight being held about 4-6 inches from the nose and observe for pupil constriction.

Answer and Explanation

The Correct Answer is B

: Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction. This is the appropriate technique to assess pupillary reaction. The nurse should stand to the side of the patient and use a penlight or other focused light source to illuminate one pupil at a time. The light should be directed from the side of the eye, not directly in front of it, to avoid stimulating the accommodation reflex. The nurse should observe for constriction of the pupil, which should occur in response to the light. This assessment is important because changes in pupil size and reactivity can indicate neurological dysfunction or other medical conditions.

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Correct Answer is C

Explanation

The correct answer is choice C, Pulse amplitude. Pulse amplitude is a measure of the strength of the pulse and is rated on a 0-4 scale, with 0 indicating no pulse and 4 indicating a bounding pulse. A brisk pulse with a +2 rating suggests a normal pulse strength that is easily felt and is not weak or bounding. Pulse rhythm describes the regularity or irregularity of the pulse beats and is not related to pulse strength. Pulse deficit refers to the difference between the apical and radial pulse rates and is determined by auscultating the apical pulse while simultaneously palpating the radial pulse. Pulse arrhythmia refers to an irregular pulse rhythm.

A. increased respiratory rate B. confusion C. cyanosis D. restlessness E. dyspnea F. Bradychardia G. Hypertension H. Nausea and vomiting

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

Explanation

The correct answer is choices A, B, C, D, and E.

Hypoxia occurs when there is inadequate oxygen supply to the body's tissues. Signs of hypoxia can vary depending on the severity of the condition. The following signs can indicate hypoxia:

Increased respiratory rate - Hypoxia can cause an increased respiratory rate as the body tries to increase oxygen levels in the blood.
Confusion - Hypoxia can affect cognitive function, leading to confusion.
Cyanosis - Hypoxia can cause a blue or purple discoloration of the skin, lips, or nail beds due to the lack of oxygen.
Restlessness - Hypoxia can cause restlessness or agitation.
Dyspnea - Hypoxia can cause difficulty breathing, also known as dyspnea.
Bradycardia - Bradycardia, or a slow heart rate, is not typically a direct sign of hypoxia. Hypoxia often leads to tachycardia (increased heart rate) as the body tries to compensate for low oxygen levels.
Hypotension - While severe hypoxia can eventually lead to changes in blood pressure, hypotension (low blood pressure) is not a primary sign of hypoxia. Typically, hypoxia might cause hypertension or have no immediate impact on blood pressure.
Nausea and Vomiting - While nausea and vomiting can be related to various conditions, they are not specific signs of hypoxia. These symptoms might occur due to other issues or as a secondary effect in some cases, but they are not primary indicators of hypoxia.

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Which technique should the nurse use to assess the pupillary reaction on a client?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

Correct Answer is C

Explanation

A nurse is assessing a patient and notes that the patient is experiencing hypoxia. Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

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

Explanation

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