A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding?
The infant's eyes turn toward the light.
The infant's head turns away from the light.
The infant's eyes remain focused toward the floor.
The infant closes their eyes.
The Correct Answer is A
A.
A. The infant's eyes turn toward the light - This is the expected finding known as the "fixation reflex," where infants naturally turn their eyes toward a light source.
B. The infant's head turns away from the light - This would not be an expected finding during a vision screening; it may suggest a different reflex or issue.
C. The infant's eyes remain focused toward the floor - This would not be an expected finding during a vision screening; it may suggest a different visual or developmental concern.
D. The infant closes their eyes - Closing the eyes in response to light is not the typical response during a vision screening for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Limit each of the client's visitors to 1 hr per day. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and
the client's condition, not solely on the presence of a radiation implant.
B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.
C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.
D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate
protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.
Correct Answer is A
Explanation
A.
A. Assessing the client's pain level is the first step to ensure appropriate pain management during the procedure.
B. Irrigating the wound comes after assessing the client's pain level and preparing the wound for the dressing change.
C. Applying skin preparation to wound edges is part of the preparation process but should come after assessing the client's pain level.
D. Donning sterile gloves is necessary for the procedure but should come after assessing the client's pain level.
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