While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

The right pupil constricts and the left consensually responds.

Both pupils are equal in size and constrict readily to the light source.

Bilateral pupil size changes as the distance of the light source varies.

The left iris is "notched" and the pupil size changes minimally.

Answer and Explanation

The Correct Answer is D

A.   This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B.   This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C.   Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D.   This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

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Correct Answer is D

Explanation

A. Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B. Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C. Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D. Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

A. Otitis media. B. Neurological pathology. C. Tinnitus. D. Hearing loss.

Correct Answer is D

Explanation

A. Otitis media is an infection of the middle ear, and while it can affect hearing, it is not typically assessed using a tuning fork. Tuning forks are more useful for evaluating conductive hearing loss or bone conduction.
B. A tuning fork is generally not used to assess neurological pathology directly. Neurological conditions often require other diagnostic tools or tests to evaluate nerve function or reflexes.
C. Tinnitus is the perception of ringing in the ears and is usually assessed through patient reporting and audiometric testing. A tuning fork is not used to diagnose tinnitus, but it may be used to test hearing acuity.
D. A tuning fork is commonly used to assess for hearing loss, specifically conductive hearing loss. The fork helps test the function of bone and air conduction, which are important for determining the type of hearing impairment.

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While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Correct Answer is D

Explanation

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

Correct Answer is D

Explanation

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