What is the condition called when the client's pupils are different sizes and have been this way since childhood?

Correct Answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

Correct Answer: A

Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.

Correct Answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

Correct Answer: A

Rationale: **Rationale:** **A: Client who had recent cataract surgery and worsening vision** is the highest priority. Postoperative complications following cataract surgery, such as endophthalmitis (a severe intraocular infection) or retinal detachment, can lead to rapid and irreversible vision loss if not addressed immediately. Worsening vision after cataract surgery is a red flag that demands urgent evaluation to rule out these sight-threatening conditions. Delay in treatment could result in permanent damage, making this client the top priority. **B: Client with an absent red reflex** is concerning but may not always require immediate intervention. An absent red reflex can indicate conditions like retinal detachment, vitreous hemorrhage, or advanced cataracts. While serious, some causes (e.g., dense cataract) may not be emergencies, whereas others (e.g., retinal detachment) would be. However, without additional symptoms like acute vision loss or pain, this finding alone is less urgent than a postoperative complication. **C: Client with an intraocular pressure (IOP) of 24 mmHg** is not the most urgent case. While elevated IOP can suggest glaucoma, 24 mmHg is only mildly elevated and may not cause immediate harm. Acute angle-closure glaucoma (which presents with severe pain, vision loss, and IOP >40 mmHg) would be emergent, but this scenario lacks those symptoms. This client can be seen after more urgent cases. **D: Client with a tearing, reddened eye with exudate** likely has conjunctivitis, which, while uncomfortable, is typically non-vision-threatening and not an emergency. Bacterial or viral conjunctivitis can be managed with topical treatments and does not require immediate attention unless there is corneal involvement or severe pain, which is not indicated here. This client can wait compared to the postoperative case. In summary, **A** is the correct answer because postoperative vision changes after cataract surgery are potentially sight-threatening and require immediate assessment. The other options involve conditions that, while notable, are either less urgent or lack the immediate risk of permanent vision loss.

Correct Answer: A

Rationale: The correct action is to assess the right radial pulse first because the client's symptoms (numbness in the right hand after a crushing injury to the right arm) suggest potential vascular compromise or compartment syndrome. A crushing injury can lead to swelling, increased pressure within the fascial compartments, and subsequent compression of nerves and blood vessels. The radial pulse is a direct indicator of arterial perfusion to the hand. If the pulse is weak or absent, this signals impaired blood flow, which is a medical emergency requiring immediate intervention to prevent tissue necrosis or permanent damage. Assessing the pulse provides critical data to guide further actions, such as notifying the provider or preparing for possible surgical intervention (e.g., fasciotomy). **Why other options are incorrect:** - **B: Call the provider** – While notifying the provider is important, it should occur *after* gathering initial assessment data (e.g., pulse, capillary refill, pain characteristics). Without assessing the radial pulse first, the nurse lacks objective information to communicate to the provider, which could delay appropriate treatment. The provider will need specific findings (e.g., pulse quality, signs of ischemia) to make clinical decisions. - **C: Administer pain medication** – Pain management is a priority in trauma, but numbness (not pain) is the primary symptom here, indicating possible neurovascular compromise. Administering analgesics without first assessing circulation could mask worsening symptoms (e.g., unrelenting pain from ischemia) and delay lifesaving interventions. Pain relief should follow the evaluation of vascular and neurological status. - **D: Assess the right pedal pulse** – A pedal pulse evaluates circulation to the foot, which is irrelevant in this scenario. The injury is localized to the arm, and the symptom (hand numbness) points to radial artery or peripheral nerve involvement in the upper extremity. Checking a pedal pulse wastes time and does not address the immediate concern. In summary, the radial pulse assessment is the most urgent action because it directly evaluates perfusion to the affected limb, aligns with the client's symptoms, and informs subsequent interventions. The incorrect choices either delay critical assessment, address unrelated systems, or prioritize less urgent interventions without proper clinical justification.