During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes.
The nurse should recognize that this is:.
A normal finding
An abnormal finding: the child needs referral to an ophthalmologist
A sign of a possible visual defect; the child needs vision screening
A sign of small hemorrhages, which usually resolve spontaneously
The Correct Answer is A
A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.
Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.
Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.
A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.
Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.
Hemorrhages can be caused by diabetes, hypertension, or trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Sleepiness or fatigue and puffiness around the eyes are symptoms associated with hypothyroidism. Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones, which regulate the body’s metabolism and energy levels.
Choice A is wrong because weight loss is more likely to occur in hyperthyroidism, a condition where the thyroid gland produces too much thyroid hormones.
Choice C is wrong because diarrhea is also more likely to occur in hyperthyroidism, as the excess thyroid hormones speed up the digestive system.
Choice E is wrong because limited hair growth is not a specific symptom of hypothyroidism. Hair loss or thinning may occur in both hypothyroidism and hyperthyroidism, depending on the severity and duration of the condition.
Normal ranges for thyroid hormones are:
- TSH: 0.4 to 4.0 mIU/L
- T3: 100 to 200 ng/dL
- T4: 4.5 to 11.2 mcg/dL
Correct Answer is D
Explanation
This is because toddlers continue to have the short, straight internal ear canal of infants.
The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose the toddler to frequent infections.
Choice A is wrong because respirations are abdominal. This does not affect the susceptibility to infection.
Choice B is wrong because pulse and respiratory rates are slower than those in infancy. This also does not affect the susceptibility to infection.
Choice C is wrong because defense mechanisms are less efficient than those during
infancy. This is not true, as the defense mechanisms are more efficient compared with those of infancy.
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