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 A

Explanation

A. Wheezes:

Wheezes are continuous, high-pitched, whistling lung sounds that are heard especially during expiration and sometimes during inspiration. They are caused by the rapid movement of air through narrowed or constricted airways, which is common in conditions like asthma. Wheezing is a characteristic adventitious sound associated with asthma and other obstructive respiratory disorders.

B. Whispered Pectoriloquy:

Whispered Pectoriloquy is an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields. This phenomenon occurs when sound is transmitted clearly through consolidated or compressed lung tissue, making whispered sounds more distinct. It is a sign of lung consolidation, often seen in conditions like pneumonia.

C. Bronchial Sounds:

Bronchial sounds are harsh, high-pitched sounds heard over the trachea and the large bronchi. These sounds are normally heard during expiration. If they are heard over peripheral lung areas, it can indicate consolidation or compression of lung tissue, possibly due to pneumonia or tumor.

D. Bronchophony:

Bronchophony is a phenomenon in which spoken sounds are heard more clearly and distinctly through the stethoscope on auscultation of the lungs. Normally, sounds are muffled during auscultation. Increased clarity of spoken sounds can indicate lung consolidation, similar to whispered pectoriloquy, and is often associated with conditions like pneumonia.

A. When part of the lung is obstructed or collapsed B. When bulging of the intercostal spaces is present C. In an obese patient D. When accessory muscles are used to augment respiratory effort

Correct Answer is A

Explanation

A. When part of the lung is obstructed or collapsed: This statement is accurate. Unequal chest expansion can occur when part of the lung is obstructed or collapsed, preventing the affected area from expanding normally during inhalation.

B. When bulging of the intercostal spaces is present: This statement is not accurate. Unequal chest expansion typically refers to decreased expansion on one side, not bulging of intercostal spaces.

C. In an obese patient: This statement is not accurate. Obesity can affect breathing patterns and lung function, but it is not the primary cause of unequal chest expansion.

D. When accessory muscles are used to augment respiratory effort: This statement is not accurate. The use of accessory muscles to augment respiratory effort can be a sign of respiratory distress, but it doesn't directly cause unequal chest expansion. Unequal expansion is more indicative of specific lung conditions or issues with lung mechanics.

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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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