The nurse is assessing a client admitted on the medical surgical unit. The patient has no complaints of pain or distress noted. The temp is 98.6°F, pulse of 88, respirations of 18 and blood pressure of 172/88. The patient's electronic health record notes a diagnosis of esotropia that has been present for the past five years. The nurse is providing an external eye exam. What priority finding would the nurse expect from the client?

Bilateral eye malalignment

Left eye turning outward

Left eye oscillating when performing oculomotor exam

Right eye turning inward

Answer and Explanation

The Correct Answer is D

Choice A reason: Bilateral malalignment implies both eyes misalign variably, but esotropia specifies inward deviation, often unilateral. This vague term doesn’t match the precise diagnosis of esotropia present for five years, making it less expected here fully.
Choice B reason: Left eye turning outward is exotropia, not esotropia, which turns inward. This contradicts the client’s documented condition, misaligning with the expected inward deviation from cranial nerve VI or muscle imbalance entirely and accurately here.
Choice C reason: Oscillating eyes suggest nystagmus, not esotropia’s fixed inward turn. Esotropia is static misalignment, not rhythmic movement, excluding this as the priority finding for this client’s established eye condition in this exam fully here.
Choice D reason: Right eye turning inward fits esotropia, a common misalignment where one eye deviates medially. Given the five-year history, this is the expected external exam finding, reflecting the diagnosis accurately and consistently in this case here.

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Correct Answer is B

Explanation

Choice A reason: Rapid ankle oscillations might suggest tremor, possibly basal ganglia issues, not cerebellar dysfunction. The heel-shin test assesses coordination, where cerebellar damage causes drift, not rhythmic shaking, making this less indicative of the target pathology here.
Choice B reason: Heel deviation to one side in the heel-shin test signals cerebellar dysfunction, impairing coordination. The cerebellum fine-tunes movement; damage causes ataxia, leading to inaccurate sliding, making this the key sign of cerebellar issues accurately.
Choice C reason: Pain and knee flexion suggest joint or nerve issues, not cerebellar dysfunction. This test evaluates smooth motion, not pain response; cerebellar problems show ataxia, not discomfort, disconnecting this from the intended motor assessment fully.
Choice D reason: Paresthesia (tingling) indicates sensory nerve issues, not cerebellar motor control. The cerebellum coordinates movement, not sensation; this response misses the coordination focus of the heel-shin test, excluding it as a cerebellar sign here entirely.

A. Convergent response B. Direct reflex C. Consensual response D. Accommodation

Correct Answer is C

Explanation

Choice A reason: Convergent response isn’t a standard term; convergence occurs with near focus, not light. This misnames the pupil constriction in the opposite eye from light stimulus, unrelated to the observed cranial nerve III reflex entirely here.
Choice B reason: Direct reflex is pupil constriction in the lit eye, not the other. This describes the same-side reaction, not the contralateral constriction observed, distinguishing it from the finding in this eye exam fully and accurately here.
Choice C reason: Consensual response is when light in one eye constricts the other’s pupil, via cranial nerve III. This matches the finding, reflecting normal optic and oculomotor nerve interplay, making it the precise description comprehensively here.
Choice D reason: Accommodation adjusts focus for near vision, constricting pupils bilaterally, not from unilateral light. This involves lens change, not the light-induced contralateral reflex seen, excluding it as the correct term in this scenario fully here.

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Naxlex Comprehensive Predictor Exams

The nurse is testing for motor functioning by having the client lie down and slide the heel of the right foot down the left shin and then slide the heel of the left foot down the right shin. Which response by the patient would indicate that there may be cerebellar dysfunction?

Correct Answer is B

Explanation

A nurse is completing a full assessment for their client on a telemetry unit. During the eye exam, a nurse shines a light into one of the client's eyes and the pupil of the other eye constricts. What is the most appropriate description of this finding?

Correct Answer is C

Explanation

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