Which of the following techniques should the nurse use to assess a client's pupillary response to light?
1. Briefly shine a penlight into the client's eye by passing the light from the outer edge of the eye toward the center of the eye.
2. Turn the room lights on and off quickly three times.
3. Have the client close his eyes and then quickly open them.
4. Shine the light in the center of the client's eyes for one minute then check them for movement.
1
By briefly shining a penlight into the client's eye from the outer edge toward the center of the eye and checking for movement of the pupil, the nurse can tell if there may be brain damage or nerve damage. The other choices are not appropriate technique to assess a client's pupillary response to light.
You might also like to view...
Your patient tells you that he has just had an argument with his spouse over the phone. What can you expect that his sympathetic nervous system has stimulated his adrenal gland to release?
A) Endorphins B) Dopamine C) Epinephrine D) Testosterone
A nurse is preparing to administer a second infusion of trastuzumab [Herceptin] to a patient who has breast cancer. The patient tells the nurse that she experienced chills, fever, pain, and nausea after her first infusion. What will the nurse do?
a. Contact the provider to request a CBC to assess for neutropenia. b. Ensure that oxygen and respiratory sup-port measures are readily available. c. Reassure the patient that these symptoms will diminish with each infusion. d. Request an order for an electrocardiogram.
Which of the following is NOT a common symptom of depression?
a. feelings of sadness b. decrease in appreciate c. sleep problems d. concerns about body image
A prenatal client states, "The doctor said he might have to cut my cervix so the baby can get out during delivery." Based upon this statement, what structure should the nurse define when teaching about an episiotomy?
1. Mons pubis 2. Labia majora 3. Perineal body 4. Vaginal vestibule