Author Question: The nurse is assessing the client's pupillary responses. The client is found to have no consensual ... (Read 161 times)

lidoalex · **on:** Jun 25, 2018

The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. Which conclusion by the nurse is the most appropriate?

1. Cranial nerve III may not be functioning appropriately.
2. This is a normal finding.
3. This is evidence of increased intracranial pressure.
4. This is evidence of optic nerve damage.

Question 2

During the assessment of a client's eyes, the nurse suspects that the client has ptosis. Which assessment data caused the nurse to come to this conclusion?

1. The palpebral conjunctiva is exposed.
2. The iris and cornea are reddened.
3. The eyelid is drooping.
4. The eyelids are swollen and puffy.

honnalora · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1
When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III. This is not a normal finding. Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped. This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the client's visual fields.

Answer to Question 2

Correct Answer: 3

Ptosis is drooping of the eyelid. Ectropion is eversion of the lower eyelid caused by muscle weakness that produces exposure of the palpebral conjunctiva. Iritis is characterized by redness of the iris and cornea. Periorbital edema refers to swollen, puffy eyelids.