When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.
ANS: C
To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.
You might also like to view...
The nurse who is completing an admission history on a patient diagnosed with COPD understands that the major risk factor associated with this disease process includes exposure to which of the following?
A) Toxic fumes B) Dust particles C) Cigarette smoking D) Animal dander
A nurse providing palliative care for a dying man and his family knows that the goal of palliative care is:
A) to aggressively treat the disease. B) to provide care for the dying in the home. C) to aggressively treat the symptoms of the disease. D) to support the family of the dying patient.
A nursing student is caring for a hospitalized child who has hypotonic dehydration. The nursing instructor asks the student to describe this type of dehydration
The instructor determines that the nursing student understands the physiology associated with this type of dehydration if the student states which of the following? 1. "It causes the serum sodium level to rise above 150 mEq/L." 2. "It occurs when the loss of electrolytes is greater than the loss of water." 3. "It occurs when the loss of water is greater than the loss of electrolytes." 4. "It occurs when water and electrolytes are lost in approximately the same propor-tion as they exist in the body."
An adolescent has been diagnosed with osteochondrosis. How does the healthcare professional describe the pathophysiology to the teen?
a. Imbalance between calcitonin and parathyroid hormone b. Nutritional deficiency of calcium and phosphorus c. Bacterial infection of the bone d. Vascular impairment and trauma to bone