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 ["A","B","C","D"]
Explanation
These are all positive signs of pregnancy, which are definitive and can only be explained by the presence of a fetus.A positive sign of pregnancy is fetal movement palpated by the nurse-midwife.
Choice E is wrong because a positive hCG test is a probable sign of pregnancy, not a positive one.A probable sign of pregnancy is strongly suggestive of pregnancy but could have other causes.A positive hCG test could be caused by medications, tumors, or other conditions that affect the level of hCG in the blood or urine.
Some other probable signs of pregnancy are uterine enlargement, Hegar’s sign (softening of the lower uterine segment), Goodell’s sign (softening of the cervix), Chadwick’s sign (bluish discoloration of the cervix), ballottement (rebound of the fetus when tapped by the examiner’s finger), Braxton Hicks contractions (painless, irregular uterine contractions), and positive pregnancy test.
Some other positive signs of pregnancy are identification of fetal heartbeat, visualization of the fetus by ultrasound or x-ray, and verification of fetal movement by an experienced clinician.
Correct Answer is B
Explanation
This is because a patent ductus arteriosus is a congenital heart defect that involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. This causes a continuous machinery-like murmur that can be heard on auscultation.
Choice A is wrong because pulmonary stenosis is a narrowing of the pulmonary valve or artery that obstructs blood flow to the lungs. It causes a systolic ejection murmur that is best heard at the upper left sternal border.
Choice C is wrong because the ventricular septal defect is a hole in the wall between the ventricles that allows blood to flow from the left to the right side of the heart. It causes a loud, harsh holosystolic murmur that is best heard at the left lower sternal border.
Choice D is wrong because coarctation of the aorta is a narrowing of the aorta that reduces blood flow to the lower body. It causes a systolic murmur that radiates to the back and weak or absent femoral pulses.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today