A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

Position the examination light toward the client's face.

Stand on the right side of the client when examining the left eye.

Dim the lights in the room prior to the examination.

Place the ophthalmoscope directly against the client's forehead.

Answer and Explanation

The Correct Answer is B

A. The examination light of the ophthalmoscope should be directed toward the client's eye, not the client's face.

B. When examining the left eye, the nurse should stand on the right side of the client to facilitate proper alignment of the ophthalmoscope with the client's eye.

C. Dimming the lights in the room may improve visualization of the client's internal eye

structures, but it is not typically necessary for ophthalmoscopic examination and may hinder the nurse's ability to assess the client effectively.

D. Placing the ophthalmoscope directly against the client's forehead would not facilitate proper examination of the internal eye structures and may cause discomfort to the client.

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Correct Answer is C

Explanation

A. Arterial blood gases - Arterial blood gases are not typically assessed before initiating lithium carbonate therapy.

B. Total cholesterol - Total cholesterol levels are not specifically relevant to monitoring lithium therapy.

C. Thyroid hormones - Thyroid function should be assessed before initiating lithium therapy because lithium can affect thyroid function, potentially leading to hypothyroidism.

D. Hemoglobin - While hemoglobin levels may be monitored during lithium therapy, they are not typically assessed prior to initiating treatment.

A. Head circumference 1 cm greater than chest B. Positive Babinski reflex on bilateral feet C. Passage of meconium stool D. Pinna below the outer canthus of the eye

Correct Answer is D

Explanation

A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.

B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.

C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.

D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.

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A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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