The nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?
Nystagmus in extreme superior gaze
Slight amount of lid lag when moving the eyes from a superior to an inferior position
Parallel movement of both eyes
Convergence of the eyes
The Correct Answer is C
A. Nystagmus in extreme superior gaze: Nystagmus is an involuntary eye movement and is not a normal finding, especially in extreme superior gaze. Nystagmus can be indicative of neurological issues and requires further evaluation.
B. Slight amount of lid lag when moving the eyes from a superior to an inferior position: Lid lag refers to a delay in the downward movement of the upper eyelid during eye movement. This can be a sign of hyperthyroidism and is not a normal finding.
C. Parallel movement of both eyes: This is the correct answer. During the diagnostic positions test, the nurse should observe parallel movement of both eyes in all directions, indicating normal extraocular muscle function and coordination.
D. Convergence of the eyes: Convergence refers to the inward movement of both eyes when focusing on a close object. While convergence is a normal phenomenon, it is not specifically assessed during the diagnostic positions test, which primarily evaluates the range of motion and coordination of the extraocular muscles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
. Presence of breath sounds: While assessing the anterior chest, the nurse should listen for breath sounds over various areas of the lungs. However, this is related to auscultation, not inspection.
B. Diaphragmatic excursion: Diaphragmatic excursion involves assessing the movement of the diaphragm during breathing. This is typically done by percussing the level where dullness changes to resonance during inhalation and exhalation. It is more related to percussion, not inspection.
C. Symmetric chest expansion: Symmetric chest expansion refers to the equal expansion of both sides of the chest during inhalation. The nurse can observe and palpate the chest to assess if it expands symmetrically on both sides. This is a crucial aspect of the inspection of the anterior chest.
D. Shape and configuration of the chest wall: The shape and configuration of the chest wall, including abnormalities or deformities, should be assessed during inspection. This includes observing for any asymmetry, deformities, masses, or scars on the anterior chest.
Correct Answer is A
Explanation
A. Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation. They occur in individuals who are in a supine position and disappear after a few breaths. These crackles are not indicative of any pathological condition; they are common when the lungs are not fully aerated, especially when a person is lying down.
B. Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung areas. They are soft, low-pitched, and continuous throughout inspiration and part of expiration. Vesicular breath sounds are the typical sounds heard during routine breathing and are not associated with crackling or popping noises.
C. Fine wheezes:
Wheezes are high-pitched whistling sounds heard during expiration. They occur due to narrowed airways and are commonly associated with conditions like asthma or bronchoconstriction. Fine wheezes suggest a partial obstruction in the smaller airways, causing turbulent airflow, leading to the characteristic sound.
D. Fine crackles and may be a sign of pneumonia:
Fine crackles are high-pitched, discontinuous, crackling sounds heard during inspiration. They can occur due to the sudden opening of small airways, and their presence may indicate fluid in the lungs or lung inflammation. Fine crackles are often associated with conditions such as pneumonia, heart failure, or interstitial lung diseases.
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