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 A

Explanation

A. Longitudinal ridges on the fingernails are a common finding in older adults and often do not indicate any underlying health problems. These ridges may develop due to normal aging processes as the rate of nail growth slows.
B. While COPD can cause changes in the nails, such as clubbing, longitudinal ridges are not typically associated with this condition. COPD is more likely to cause cyanosis and other signs related to poor oxygenation.
C. A fungal infection usually causes discoloration, thickening, or brittleness in nails, but not longitudinal ridges. Fungal infections would likely affect the overall appearance of the nail rather than causing isolated ridges.
D. Psoriasis can cause pitting, scaling, or thickening of the nails, but longitudinal ridges are not characteristic of this condition. Psoriasis typically affects the skin more than the nails, though it can lead to changes in nail structure.

A. Listen to the heart sounds using the bell of a stethoscope. B. Use a Doppler ultrasound to hear the heartbeat. C. Obtain a pulse oximeter reading from two extremities. D. Auscultate for one minute with the stethoscope's diaphragm.

Correct Answer is A

Explanation

A. The bell of the stethoscope is best for detecting low-pitched sounds like murmurs or extra heart sounds.
B. A Doppler ultrasound is not necessary for routine auscultation of heart sounds.
C. Pulse oximetry does not provide relevant information about heart sounds.
D. Auscultating with the diaphragm is better for high-pitched sounds, so the bell is preferred for extra heart sounds.

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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?

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Naxlex Comprehensive Predictor Exams

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate?

Correct Answer is A

Explanation

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Correct Answer is A

Explanation

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?

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