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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Xiphoid process:

The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum (breastbone). It does not play a role in the bifurcation of the trachea.

B. Suprasternal notch:

The suprasternal notch, also known as the fossa jugularis sternalis or jugular notch, is the visible dip in the superior part of the manubrium of the sternum between the clavicular notches. It is an important anatomical landmark for assessing the position of the trachea during emergency situations but is not the location of tracheal bifurcation.

C. Sternal angle (Angle of Louis):

The sternal angle, or Angle of Louis, is a palpable notch located at the articulation of the manubrium and the body of the sternum. It is where the second rib attaches and serves as a useful reference point for counting ribs and locating internal structures like the tracheal bifurcation.

D. Costal angle:

The costal angle is the acute angle formed by the junction of the costal margins at the xiphoid process. It is not related to the tracheal bifurcation.

A. Use of accessory muscles B. Nail bed greater than 160 degrees C. Circumoral cyanosis D. Pursed lip breathing E. Anteroposterior-to-transverse diameter of 1:1

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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