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
A. Perform the confrontation test:
The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.
B. Ask the patient to read the print on a handheld Jaeger card:
Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.
C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:
This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.
D. Use the Snellen chart positioned 20 feet away from the patient:
The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.
Correct Answer is B
Explanation
A. Simultaneously palpating both arteries to compare amplitude: While comparing amplitudes is important, using the diaphragm of the stethoscope to listen for bruits (abnormal whooshing sounds indicating turbulent blood flow) is a more specific and accurate method for assessing the carotid arteries for potential vascular issues.
B. Listening with the diaphragm of the stethoscope to assess for bruits: This technique allows the nurse to detect abnormal sounds (bruits) that could indicate partial blockages or stenosis in the carotid arteries, suggesting a risk of stroke or transient ischemic attack.
C. Instructing the patient to take slow deep breaths during auscultation: Deep breaths are more relevant during lung auscultation. Carotid artery assessment focuses on detecting abnormal sounds and assessing blood flow rather than respiratory patterns.
D. Palpating the artery at the base of the neck: Palpation alone does not provide enough information about potential blockages or abnormalities in the carotid arteries. Listening with a stethoscope allows for a more detailed assessment of blood flow and the presence of bruits.f the nurse hears a bruit during auscultation, they shouldnotpalpate the carotid artery. A bruit suggests partial obstruction (carotid stenosis), and compressing the artery further could worsen blood flow.
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