A nurse needs to assess the peripheral vision of a client. What test is appropriate?

Rosenbaum test

Consensual constriction

Corneal Light Reflex

Confrontation test

Answer and Explanation

The Correct Answer is D

A) Rosenbaum test: The Rosenbaum test is used to assess near vision and is typically performed with a handheld card to check for presbyopia, which is the difficulty seeing up close. It is not appropriate for testing peripheral vision, which is the focus of the current assessment.

B) Consensual constriction: Consensual constriction refers to the reaction of the pupil in the opposite eye when light is shined into one eye. This test assesses the pupillary light reflex, which evaluates how well the pupils constrict in response to light. It is not used to assess peripheral vision and focuses more on the function of the optic nerve and pupil reaction.

C) Corneal Light Reflex: The corneal light reflex is a test used to assess for strabismus (misalignment of the eyes) by checking the symmetry of the light reflection on the cornea. This test helps in diagnosing eye alignment issues, but it does not evaluate peripheral vision.

D) Confrontation test: The confrontation test is a straightforward and effective method used to assess peripheral vision. The nurse and patient sit facing each other, and the patient covers one eye while the nurse tests the other eye’s visual fields by moving their fingers in from the periphery. This test evaluates the patient's ability to detect objects in their peripheral vision and is specifically designed for this purpose.

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Correct Answer is B

Explanation

A) Trachea is midline: Palpating the neck using a three-finger technique is not typically used to assess the position of the trachea. The trachea's position is assessed by placing one finger on each side of the trachea and gently palpating to check for any deviation from the midline. This technique is different from using three fingers to assess the thyroid.

B) Location of the thyroid: The three-finger technique is often used by nurses to palpate the thyroid gland. This method helps assess the size, shape, and consistency of the thyroid as well as to check for any enlargement (goiter) or tenderness. The technique is used to help guide the nurse’s fingers to the correct area for palpating the thyroid gland, typically located just below the Adam’s apple in the neck.

C) Location of lymph nodes: The location of lymph nodes is assessed by palpating different areas of the neck using the pads of the fingers or a gentle circular motion. The three-finger technique is not typically used to assess lymph nodes. Instead, lymph nodes are individually palpated with one or two fingers to feel for enlargement or tenderness.

D) Ability for client to swallow: Swallowing ability is assessed by observing the patient while they swallow fluids or food and by asking about any difficulty with swallowing (dysphagia). The three-finger technique does not assess swallowing directly; it is a method used for palpating structures in the neck like the thyroid.

A. pearly gray tympanic membrane B. erythema tympanic membrane C. edema of the tympanic membrane D. bulging of the tympanic membrane

Correct Answer is A

Explanation

A) Pearly gray tympanic membrane: A healthy, normal tympanic membrane (eardrum) typically appears pearly gray and translucent. In the case of acute otitis media (AOM), the tympanic membrane usually appears erythematous (red) due to inflammation and may be bulging or swollen. A pearly gray tympanic membrane would be inconsistent with the diagnosis of acute otitis media, as it suggests a lack of infection or inflammation.

B) Erythema tympanic membrane: Erythema, or redness, of the tympanic membrane, is a common finding in acute otitis media. The inflammation from the infection causes the membrane to appear red or inflamed. This finding is consistent with the diagnosis of AOM and indicates irritation or infection in the middle ear.

C) Edema of the tympanic membrane: Edema (swelling) of the tympanic membrane is a common finding in acute otitis media. The middle ear becomes inflamed and fluid-filled, leading to swelling of the tympanic membrane. This is consistent with the diagnosis of AOM.

D) Bulging of the tympanic membrane: Bulging of the tympanic membrane is another classic sign of acute otitis media. The buildup of fluid and pus behind the eardrum causes it to bulge outward. This finding is consistent with AOM and indicates a more severe or advanced stage of the infection.

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A nurse needs to assess the peripheral vision of a client. What test is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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